
Class, TOb~5\ 
Book— .Vii 



/ 



3S'C 



THE EXCISION OE JOINTS. 



THE 



EXCISION OF JOINTS 






RICHARD M. HODGES, M. D 

10' 



BOSTON, 

MASSACHUSETTS 

1861. 






Entered according to Act of Congress, in the year 1861, by 

R. M. HODGES, 

in the Clerk's Office of the District Court of the District of Massachusetts. 






Cambridge : 

Welch, Bigelow, and Compant, 

Printers to the University. 



PREFACE. 



Excisions of Joints have been comparatively little prac- 
tised in the United States. The personal experience of 
any one American surgeon in regard to them is there- 
fore of a very limited character ; and American medical 
periodicals, or systematic writings, furnish but little ma- 
terial calculated to throw light upon the questions con- 
nected with this class of operations. 

British, and, to a larger extent, European medical liter- 
ature offer, however, a fertile field for their study. Owing 
their origin to an English surgeon, they have of late years 
been extensively practised throughout the United King- 
dom, and a great number of the cases in which the opera- 
tion has been performed have been published with more or 
less detail ; but, with the exception of Professor Jeffray's 
translation, in 1806, of the cases reported by the elder 
Moreau, accompanied by a reprint of the two letters of 
Mr. Park, and the work of Mr. Syme, printed in 1831, the 
English language possesses no monograph on the subject 
of Excisions. On the Continent the interest developed by 
the early experimental researches of Chaussier, Heine, and 
Wachter has found expression in the later writings of Ried, 
Wagner, J. F. and 0. Heyfelder, Esmarch, Paul, Schill- 
bach, and in numerous " inaugural dissertations.'' 

From these and other sources the following pages have 
been prepared, and were offered in successful competition 
for the Boylston Prize of 1861. As an attempt to exhibit 
the precise value of an important surgical procedure, it is 



VI PREFACE. 

hoped that they will be found not undeserving of the honor 
which they have thus received. 

Great pains has been taken in the preparation of the 
tables which accompany the consideration of each excision. 
It is believed that they are more complete than any here- 
tofore published. In their formation, valuable assistance 
has been derived from the tables of 0. Heyfelder, of St. 
Petersburg, and in that of excisions of the hip-joint from 
those of Dr. L. A. Sayre, of New York, and of Dr. C. Fock, 
of Magdeburg, Prussia. The names of the various opera- 
tors are omitted as a matter of discretion, some of the 
cases, or the statement of their final result, having been 
obtained from private sources, and being unpublished ; but, 
both in the tables and elsewhere, whenever indebtedness to 
any writer has been incurred, a full and explicit reference 
is given. 

In contrasting the results of amputations with those of 
excisions, use has been made of the statistical tables of Mr. 
Thomas Bryant. These are among the most recent, and 
are drawn up with great care, as well as derived exclu- 
sively from British practice and a metropolitan hospital. 
As this is also true of a large proportion of the tabulated 
cases of excision, the comparison seems to be a fairer one 
than it would be with tables compiled from indiscriminate 
sources. 

The accompanying standing votes of the Boylston Medi- 
cal Committee explain themselves. 

" By an order adopted in 1826, it was voted, — 

" 1st. That the Board do not consider themselves as ap- 
proving the doctrines contained in any of the dissertations 
to which premiums may be adjudged. 

" 2d. That, in case of the publication of a successful dis- 
sertation, the author be considered as bound to print the 
above vote in connection therewith." 

R. M. HODGES. 
Boston, 1861. 



CONTENTS 



EXCISIONS IN GENERAL. 

Page 

Historically considered 1 

Their Adaptation to Cases 4 

Contrasted with Amputations 11 

Their Adaptation to the Two Extremities . , . 13 

Their Results 14 

UPPER EXTREMITY. 

EXCISION OF THE SHOULDER-JOINT. 

History of 21 

Excision for Injury 25 

" " Disease 31 

Operation and After-Treatment 38 

Dissections after . . . . * 43 

Conclusions in Regard to 44 

EXCISION OF THE ELBOW-JOINT. 

History of 45 

Excision for Injury 48 

" " Anchylosis 53 

" " Disease 55 

Operation and After-Treatment 66 

Dissections after 70 

Conclusions in Regard to 73 

EXCISION OF THE WRIST-JOINT. 

History of 74 

Excision for Injury 76 

" " Disease 77 

Operation and After-Treatment 83 



Vlll CONTENTS. 

Dissections after 85 

Conclusions in Regard to 86 

EXCISIONS OF SMALL JOINTS OF THE HAND ... 87 

LOWER EXTREMITY. 

EXCISION OF THE HIP-JOINT. 

History of 90 

Excision for Injury 92 

" " Deformity 96 

" " Disease 97 

Operation and After-Treatment . . . . .120 

Dissections after 123 

Conclusions in Regard to . . . . . .124 

EXCISION OF THE KNEE-JOINT. 

History of 126 

Excision for Injury 129 

" " Deformity 133 

" " Disease 136 

Growth of Limb after Excision 153 

Operation and After-Treatment 158 

Dissections after 168 

Conclusions in Regard to 169 

EXCISION OF THE ANKLE-JOINT. 

History of 170 

Excision for Injury . . . . . . . . 172 

" " Disease 177 

Operation and After-Treatment .... . 185 

Dissections after 187 

Conclusions in Regard to 187 

EXCISIONS OF SMALL JOINTS OF THE FOOT . . .188 



BIBLIOGRAPHY 193 

INDEX 201 



EXCISIONS IN GENERAL 



HISTORICALLY CONSIDERED. 

In 1783, Henry Park of Liverpool published a letter 
which he had written to Percival Pott, proposing excision 
as a cure for diseases of the knee and elbow joints. This 
was the first definite allusion made to the subject, and he 
says he was especially led to the proposal by its having 
" been the invariable custom at the Liverpool Infirmary, 
for more than thirty years, to take off the protruded ex- 
tremities of bones in cases of compound dislocation." 1 

The practice of removing the articulating extremities 
of dislocated bones appears, however, to be older than 
the Liverpool Infirmary, for Hippocrates says: "At re- 
sectiones ossium perfects circa articulos et in pede, et 
in manu, et in tibia ad malleolos, et in cubitu ad junc- 
turam manus, plerisque quibus resecantur, innoxiae sunt, 
si non statim animi deliquium evertat aut quarta die 
febris continua accedat." 2 And Celsus, in a section on 
compound dislocations, observes, although more briefly 
and less definitely : " Si nudum os eminet, impedimen- 
tum semper futurum est, ideo quod excedit abscindendum 
est." 3 Paulus JBgineta also says: "Si extremitas ossis 
prope articulum (carie) affecta fuerit, resecare ipsam op- 

1 H. Park and P. F. Moreau. Cases of Excision of Carious Joints, with 
Observations by J. Jeffray, (Glasgow, 1806,) p. 72. 

2 De Articulis, LXXIX. 

3 Milligan's Ed., p. 446. 

1 



2 EXCISIONS IN GENERAL. 

portet." 1 But in none of the subsequent ancient writers 
is there more than a mere allusion to the operation ; and 
this, too, without any detail of cases or method of per- 
formance. 

As the book containing the passage quoted from Hip- 
pocrates is of very doubtful authenticity among critics, 
and since Celsus never practised either medicine or sur- 
gery, the credit of reintroducing the excision of joints, 
as a surgical procedure, certainly equals that of its in- 
vention, and unquestionably belongs to recent times. Al- 
though we are indebted to Mr. Park for the first distinct 
publication on the subject, yet the credit of the practical 
demonstration of these operations, and their application 
to the joints generally, is due to the MM. Moreau, father 
and son, of Bar sur Ornain, France. 

In the " subsequent observations," dated September 10, 
1805, which accompany the reprint of his letters, pub- 
lished with additions by Professor Jeffray of Glasgow, 
Park himself declares that but for Moreau excisions would 
have fallen into oblivion, and laments that, although the 
army and navy of Great Britain since their announce- 
ment had passed through a long and bloody war, re- 
moval of the joint saved the limb of no British subject^ 
notwithstanding he had so strongly urged the propriety 
of the operation on the attention of military surgeons, 
(p. 59.) And yet in 1803 the Moreaus had repeatedly 
excised nearly all the larger articulations, and the younger 
boasts that their " town has become in some sort the ref- 
uge of the unfortunate, afflicted with carious joints, after 
they have tried all the means usually recommended by 
professional men, or have had recourse to empirical nos- 
trums, and when amputation seemed to them the last 
resource." 2 

So early as 1786, experiments were commenced for the 
purpose of ascertaining to what degree the limb from 

1 Liber VI. Chap. 77. 2 Jeffray's Park and Moreau, p. 115. 



HISTORICALLY CONSIDERED. 6 

which a joint had been excised was useful, and whether 
excisions might advantageously be substituted for ampu- 
tations. Vermandois appears to have been the first to 
undertake them, and the dogs from which he had suc- 
cessfully removed the head of the femur were kept in view 
for long periods of time. 1 The results which he obtained 
were subsequently confirmed by Chaussier, Koler, and 
Wachter, who also excised the head of the humerus with 
success. But operations on the ginglymoid joints, though 
none of the animals died, were, in the hands of Chaussier 
and Heine, almost, if not entirely, unsuccessful, the limb 
hanging motionless and incapable of supporting weight, 
even at the end of a year from the operation. 2 

The impossibility of deducing from these experiments 
any conclusions, except perhaps as to the risk of life, is 
too obvious to require comment, since success depends so 
much upon the after-treatment, which of course could not 
be applied in such cases. They seem, therefore, to have 
been of slight practical value, and to have produced but 
little impression. 

Between 1786 and 1789, the elder Moreau presented 
various memoirs on the subject to the French Academy, 
but they met with the most violent opposition, and many 
of his cases now lie forgotten and lost amongst the unpub- 
lished papers of that body. 3 As a consequence, excisions, 
with the single exception of that of the head of the hume- 
rus, — which, since 1812, chiefly from the example of Percy, 
Sabatier, and Larrey, has been not infrequently practised, 
as well for disease as for gun-shot injury, — were but rarely 
performed in the early part of the present century. But 
in 1831, Mr. James Syme of Edinburgh became an ear- 
nest advocate for their application to the elbow ; in 1845, 
Mr. William Fergusson of London assumed a similar posi- 
tion with regard to the hip, and in 1850 to the knee joint. 

1 Journ. de Med., Vol. LXYI. p. 200. 

2 G. H. Wachter, De Articulis Extirpandis, (Groningen, 1810,) p. 61. 

3 Jeffray's Park and Moreau, p. 82. 



4 EXCISIONS IN GENERAL. 

Within the last few years, therefore, they have been fre- 
quently performed, although it is chiefly in Great Britain 
that they have been popularized and adopted by the gen- 
erality of surgeons. 

Brilliant in themselves, these operations constitute a 
striking instance of the tendency of modern times to what 
Mr. James Prior, in 1844, first called " conservative sur- 
gery," though its doctrines, at least so far as the preser- 
vation of limbs is concerned, are a century older. 1 As far 
back as 1745, after the experience of the battle of Fontenoy, 
a French army surgeon, named Boucher, professed conser- 
vatism in these words : " Dans le nombre de 165 blesse's il 
n'y en a aucun que je sache a l'e*gard de qui la confiance 
qu'on a eu dans la Nature en pareil cas a 6te de'cue. L'art 
se reserve de ressources infinies et peut porter a la Nature 
toutes sortes de secours pour exempter de l'amputation ; 
au contraire il n'a presque rien a opposer aux inconve*ni- 
ens qui accompagnent indispensablement l'amputation." 2 



THEIR ADAPTATION TO CASES. 

It is only as a substitute for amputation in traumatic 
lesions, and in certain organic ones, that the proposition of 
excising the joints has been entertained, excepting in those 
comparatively few instances in which this operation has 
been undertaken for the cure of deformities, or in disease 
of the hip-joint where it is the sole operative alternative. 

1. Excision for Injury. — The general consent of sur- 
geons has established the propriety, under given circum- 
stances, of substituting for amputation the excision of cer- 
tain joints affected with traumatic lesions, whether from 

i Lancet, Dec. 21, 1844. 2 Mem. de l'Acad. de Chir., Tom. II. p. 211. 



THEIR ADAPTATION TO CASES. 5 

gun-shot or other causes. The weight of favorable testi- 
mony is so great as to forbid a difference of opinion. 
The systematic operations of Hey, Taylor, and Sir Astley 
Cooper ; those dictated by common sense which are occa- 
sionally done by almost all surgeons ; the decisive opinions 
of Percy, Larrey, Guthrie, and Hennen, as also the ex- 
perience of modern campaigns, set forth in the reports of 
Baudens, Macleod, Stromeyer, and Esmarch, all render a 
unanimous approval, both of the operation and the results 
which follow it. 

An American authority, Dr. F. H. Hamilton, says : " If 
we consider the question of the life of the patient only, 
the argument and the testimony seem to favor resection 
in a great majority of cases of compound dislocation oc- 
curring in large joints, and in a considerable number of 
cases in the smaller joints. It is certainly more safe than 
non-reduction, or reduction without resection, and it is 

probably quite as safe as tenotomy There seems 

sufficient authority in the facts collected to conclude that 
resection is applicable to certain compound dislocations of 
the clavicle, humerus, radius and ulna, fingers, femur, 
tibia and fibula, and toes." 1 

It is to be borne in mind, with regard to the success of 
excisions in military practice, that the different circum- 
stances of campaigns, or even of battles, greatly modify 
the character of injuries, of operations, and their results. 

Take, for example, the change in the nature of wounds 
brought about by the introduction of conical bullets. A 
Crimean surgeon says : " When the old round ball strikes 
a bone such as the femur, it does not necessarily pene- 
trate its spongy substance or comminute its shaft. If it 
does, although the injury is sufficiently great, it is a per- 
fect bagatelle to the effects of the conical ball, which, sel- 
dom deflected from its course, grinds through the spongy 
bones, breaking up their laminae, shatters the shafts of 



1 Treatise on Fractures and Dislocations, (Philad., I860,) p. 712. 
1* 



b EXCISIONS IN GENERAL. 

long bones, driving the splinters into the medullary canal 
and among the surrounding soft parts, and frequently 
fissures the rest of the shaft as far as either epiphysis." 1 
Here are circumstances which must affect not only the 
results of any operations, but may even exclude excisions 
from amongst those of feasible performance. 

Or, comparing the siege of Sebastopol and its organ- 
ized hospitals, to which soldiers could be admitted with- 
in an hour or two of their accidents, and treated until the 
natural termination of their cases, with the more recent 
Italian campaign, where the army was always on the 
move, its ambulances in the open field, under a summer's 
sun, with perhaps insufficient means, either personal or 
material, and it is easy to conceive that a difference of 
mortality must follow operations performed under such 
varying conditions. 2 Such a contrast is well presented in 
a careful paper on Injuries of Joints, by Mr. R. Alcock. 3 
He gives the following table, derived from the occur- 
rences of a single year of the Peninsular War. 

Circumstances. 

Favorable, 

More or less unfavorable, 

From which it appears, that about the same number of 
amputations were practised in each set of cases, viz. in 
rather less than one half of the wounds, but that the mor- 
tality of the second class more than doubled that of the 
first. These statements certainly go far to show with how 
little assurance inferences for the future can be drawn 
from the past, in a matter involving so many considera- 
tions as military surgery. 

The fact cannot, however, be concealed, that excisions, 

1 Edinb. Monthly Journ. of Med. Science, July, 1859, p. 67. 

2 The practice of conservative surgery was very limited in Italy, and in the 
lower extremity almost abandoned, early amputation being performed instead. 
Syst. of Surg, by T. Holmes, (Lond. 1861,) Vol. II. p. 95. 

3 Med.-Chir. Trans., Vol. XXIII. p. 294. 



No. of 
Wounded Joints. 


No. of 
Amputations. 


Total No. of 
Deaths. 


43 


19 


10 


39 


18 


24 



THEIR ADAPTATION TO CASES. 7 

excepting those of the head of the humerus and of the 
elbow, which seem to be especially privileged, are not 
operations liable to succeed under any circumstances in 
the hospitals of an army. Discussing this question, M. 
Scrive says : " L'experience acquise en Crim6e sur les in- 
teressantes questions qui concernent les amputations a 
ddmontre* que ces moyens d'extreme ressource doivent etre, 
a la guerre, largement appliquees. Si Ton h^site dans 
les cas paraissant douteux, ou si Ton se place un peu trop 
sur la terrain dite conservatrice, on ne tardent pas a s'en 
repentir, et a voir succomber aux suites de leur blessures 
des blesse's que souvent l'amputation aurait pu sauver. 
Nous avons fait trop souvent cette triste experience. En- 
traine's par un sentiment de coeur qui s'appuyait sur une 
espe*rance trompeuse, nous tentions pour le plus grand 
interet d'avenir d'un officier, par exemple de lui con- 
server un membre et de lui permettre de continuer par 
ce bienfait la brillante carriere des armes ; le sort se 
jouait de nos efforts, et les conditions generates niau- 
vaises de la sante publique, les difficultes d'une hospitali- 
sation encombree et insalubre finissaient par conduire 
l'infortune blesse au tombeau." 1 

2. Excision for Deformity. — With reference to its 
adaptation as a means of curing deformities, (and in this 
term, as here used, hardly anything but the varying forms 
of anchylosis is included,) apart from the great danger 
and the uncertainties belonging to the operation itself, 
questions of expediency arise having reference to the pa- 
tient's position in life, to the degree and nature of the 
deformity, and to the extent of its interference with ab- 
solutely necessary uses or pursuits, which are not always 
of easy decision, and which admit of discussion only in 
certain cases, and with regard to particular joints. Mr. 
Bryant speaks of a painter who desired anchylosis of his 

1 Relation Medico-Chirurgicale de la Campagne d'Orient, par le Dr. G. 
Scrive, (Paris, 1857,) p. 461. 



8 EXCISIONS IN GENERAL. 

arm in a straight position ; and of a turner, whose knee, 
at his own request, was permitted to stiffen at a right- 
angle, as that position allowed him to turn his wheel. 1 
Such instances serve to show that the deformities usually 
considered to justify treatment by excision do not always 
render a limb useless, or necessarily prove a hindrance 
to self-support. 

3. Excision for Disease. — The organic lesion most fre- 
quently treated by excision is what is familiarly called 
" white-swelling," — a term implying formidable disease 
of the joint, having no specific character, usually occur- 
ring in unhealthy constitutions of the sort called stru- 
mous or scrofulous, sometimes spontaneous and some- 
times resulting from injury, and which gives place to a 
returning healthy condition slowly, ,if at all. Its most 
prominent characteristics are a degeneration of the syno- 
vial membrane into a fibro-gelatinous mass, (distinct from 
anything following acute synovitis,) ulceration of the car- 
tilages, and caries of the articular extremities of the 
bones, from either one of which structures the disease 
may have taken its point of departure. Whilst its milder 
forms sometimes admit of recovery with anchylosis, the 
graver cases pass on to a condition in which the total 
destruction of the cartilages and ligaments, and the sep- 
aration of particles or considerable portions of diseased 
bone, destroy the possibility of recovery. Especially is 
this the case in those not infrequent instances where the 
cartilage is detached in flakes, or, as it is called, is 
" shed." The separated pieces, with the exfoliated bone, 
acting within the joint as foreign bodies, an unhealthy 
inflammation is set up in the contiguous tissues, the 
spongy structure of the bone becomes infiltrated with pus, 
abscesses form, and sinuses burrow into the soft parts. 
The outlets for discharge being insufficient, the contents 

1 Diseases and Injuries of Joints, (Lond. 1859,) p. 121. 



THEIR ADAPTATION TO CASES. 9 

of the joint are tardily removed, and the changes which 
take place are so slowly performed, that the local trouble 
not uncommonly reacts upon the general health, and life 
is only preserved by the sacrifice of the joint or the limb. 

No diseases are more difficult of exact diagnosis than 
those of articulations. Experienced surgeons are de- 
ceived as to the expected condition of an opened joint, 
and daily observation shows the impossibility of deter- 
mining with confidence the precise nature or amount of 
disease, even in cases apparently demanding the grave 
alternative of amputation or excision. This is perhaps 
the reason why the question, when and to what degree 
excisions, applied for the cure of organic lesions, are cer- 
tain, or even likely, to be followed by success, is still so 
far from being definitely settled ; any favorable inferences 
capable of being drawn from operations performed for in- 
juries becoming inapplicable to those for disease, when it is 
remembered tUat the latter occur in, or are originated by, 
a predisposing unhealthy state of the constitution. 

It is not to be forgotten that, even in cases of very consider- 
able severity, disease of a joint will sometimes, after proper 
local and hygienic management, result in a cure, — in the 
upper extremity with a fair amount of motion, in the lower 
with more or less anchylosis. This is especially true of 
cases occurring in early youth ; the natural powers, under 
favorable influences, usually sufficing to effect a cure ; and 
if the disease is too severe to admit of this, it will very 
often be found associated with a constitutional state in- 
compatible with healthy reparative action of any kind. In 
advanced life, affections of the joints are rare ; and when 
occurring, the subjects of them are usually unfitted to 
bear the exactions of long continued disease, or the slow 
convalescence from an operation. 

Time, unassisted and alone, is of itself a powerful cura- 
tive agent. " When I see," says Yidal, " the haste with 
which some surgeons avail themselves of terrible resources, 
before time has had its fair chance, I can only commiserate 
both the patient and the surgeon. By its aid we gain the 



10 EXCISIONS IN GENERAL. 

benefit of rest or of medicines, or medicinal waters, which 
produce effect only after long and persevering administra- 
tion, or of a change of climate, which, modifying the whole 
organism and changing the temperament, sometimes cures 
diseases which more than once the saw and the knife have 
itched to remove." 1 

The powerful influences of Hygiene, well appreciated by 
the founders of infirmaries at Margate, Harrowgate, and 
Southport, on the southern coast of England, for convales- 
cents and others from the London hospitals, and at Berck, 
near Calais in France, for scrofulous children from the 
Paris hospitals, are graphically described by a writer, who 
says, that a visit to these institutions " will afford to any 
one an accumulation of evidence of the wonderfully invig- 
orating influence of the sea-shore. There he will see 
carious tarsi, which, according to the ordinary principles 
of surgery, suggest no other alternative as regards treat- 
ment than that between Syme and Chopart ;»joints • already 
condemned to excision, diseased cervical vertebrae, in which 
a little further progress must be sudden and certain death ; 
hideous cases of lupus and of so-called* glandular swell- 
ings ; — in all these and many other forms of disease, the 
immediate result of removal to the sea air is the manifesta- 
tion of a tendency to a favorable termination which did not 
before exist. Ill-conditioned sores,' the sure indices of 
dead bone beneath, assume a healthy aspect ; sequestra, 
which under other circumstances would require the knife 
for their removal, become imprisoned in newly-formed bone 
and disappear ; and a disease (caries) to which, according 
to a very high authority (Mr. Syme), there is no natural 
limit except the life of the patient, terminates spontane- 
ously in cure. Even in those cases in which the knife can- 
not be wholly dispensed with, the surgeon operates under 
circumstances most conducive to a favorable result." 2 

There is, therefore, a preservative as well as a conserva- 
tive surgery of diseased joints. 

1 Tr. de Path. Ext., Tom. V. p. 567 ; see also Lancet, Mar. 23, 1861. 

2 Brit, and For. Med.-Chir. Rev., Jan. 1856, p. 85. 



EXCISIONS AND AMPUTATIONS CONTRASTED. 11 



EXCISIONS AND AMPUTATIONS CONTRASTED. 

There are certain essential peculiarities belonging to 
excisions, as contrasted with amputations, which charac- 
terize them as mere operations, and are not without influ- 
ence on their results. They have to do with the cancel- 
lated structure of the extremities of bones, which widely 
differs from the dense and non-vascular shaft implicated in 
amputations, and, instead of one small surface, present two 
large ones, filled with numerous veins, remaining patulous 
in the canals which contain them. These are especially 
adapted, if excited by the admission of air, the friction of 
the opposing part, or the irritation of bone-dust left in the 
cancelli, to set up profuse suppuration, to engender phlebi- 
tis, myelitis, and the conditions most favorable to pyaemia 
and the formation of purulent deposits. They are frequently 
performed in the midst of more or less disorganization of 
the soft parts, and although the change for the better which 
takes place in these on the removal of carious and dying 
bone may be rapid and remarkable, amputation has always 
the advantage of being undertaken only upon healthy tis- 
sues. Extreme degeneration is considered by some to be 
decisive against excision. 

Little comparatively is required of a surgeon after an am- 
putation. The consequences of its management, whether 
skilful or otherwise, can only show themselves in a good 
or a bad shaped stump; but in the treatment, and, as it 
is sometimes technically called, " the putting up " of an 
excision, want of skill or care endangers the limb, if not 
the life ; a serviceable and comely result depends upon pa- 
tient personal superintendence, and upon well-chosen and 
well-fitting apparatus. 

So much being said against excision as compared with 
amputation, it may be urged on the other side, that an 
excision ought to be, theoretically, safer than the amputa- 



^^ 



12 



EXCISIONS IN GENERAL. 



tion it supplants, since the latter must be performed at a 
point nearer the trunk ; for it has been indisputably proved, 
by surgical statistics, that the mortality after amputation in- 
creases, cceteris paribus, in exact proportion as we approach 
the trunk, every additional inch removed augmenting the 
danger to the patient. This is well shown in the statistics 
drawn from Crimean experience, which present the follow- 
ing results illustrating this progressive mortality. 1 



Amp. at shoulder-joint, . 


33.4 


" of arm, . 


26.4 


" of fore-arm, . 


5 


" of fingers, 


0.9 


" at hip-joint, 


100.0 


11 at thigh (upper third), 


87.0 



Amp. at thigh (middle third), 
" " (lower third), 

" at knee-joint, 
" of legs, 
" at ankle, 
" at medio-tarsus, . 



60.0 
56.6 
55.5 
35.6 
16.6 
14.3 



The same fact is also made apparent in Malgaigne's sta- 
tistics of amputations for disease, derived from the hos- 
pitals of Paris, and which give for the foot a mortality of 
10.34, for the leg, 48.58, for the thigh, 60.78 per cent ; for 
the fore-arm, 29.41, the arm, 39.34, and the shoulder-joint, 
50.0 per cent. 2 

Besides the above consideration, it may also be observed, 
that no nerves of any size are divided, and, the large vessels 
being untouched, hemorrhage at the time of the operation, 
and the liability of its occurrence secondarily, are very much 
less than in amputations. The shock, too, is undoubtedly 
less, since the blood contained in the limb is not lost ; but 
in saying this, it must not be forgotten that the shock is 
very great, and that death from it does sometimes occur, 
especially after excision of the larger articulations. 

Simply because the operation is less fatal, is not, how- 
ever, a sufficient reason for excision to replace amputation. 
Indeed, it will be found that in this respect there is 
actually but little difference between them. The real 



1 Notes on the Surgery of the Crimean War, by G. H. B. McLeod, (Lond. 
1856,) p. 433. 

2 Arch. Gen. de Med., Avril et Mai, 1842. 



THEIE ADAPTATION TO THE TWO EXTKEMITIES. 13 

question at issue is, whether, all things considered, am- 
putation can be averted, excision substituted for it, and the 
usefulness of the limb preserved in a sufficient degree to 
render the operation an improved method of surgical treat- 
ment ; and into this question the consideration of mortality 
does not enter, except so far as to give assurance that the 
preservation of the limb is not bought at such an additional 
sacrifice of life as to more than compensate for the advan- 
tages gained. The merits of this question will be ex- 
amined in connection with the individual excisions. 



EXCISIONS CONSIDERED IN THEIR ADAPTATION TO 
THE TWO EXTREMITIES. 

It need hardly be said, that a great diversity exists in 
the applicability of this operation to the different joints of 
the two extremities. An excision in the lower extremity, 
which is designed to support the weight of the body, and 
is the chief agent in locomotion, had better have given 
place to amputation, unless the limb regains, as its result, 
a certain amount of positive usefulness. On the other 
hand, an excision in the upper extremity, — which, with 
gentler movements to execute, has no weight to sustain, 
acts independently of its fellow, and admits of exercise and 
locomotion during the processes of cure, — even if unsuc- 
cessful, leaves the body certainly, and the limb probably, 
no worse than before the operation. An arm may be 
shortened, arrested in growth, deprived of certain uses 
and limited in others, and still remain of the greatest 
service. This difference is still further shown, when the 
admirable substitutes for the lower extremity which me- 
chanical ingenuity has furnished are remembered, whilst 
the most imperfect and partial motions of the hand sur- 
pass in usefulness those of the best artificial contrivances 
which have yet been invented. 
2 



14 EXCISIONS IN GENERAL. 

The extent to which the removal of bone is admissible 
varies for the two limbs, and so consequently, in certain 
cases, does the propriety of excision. If the disease of a 
knee-joint be so considerable that its removal renders ne- 
cessary an amount of mutilation such that the bones when 
opposed would have an insufficient basis for support, ex- 
cision cannot be the appropriate operation ; yet we may 
have 14J inches of the bones of the upper extremity taken 
away without the usefulness of the limb being altogether 
destroyed. 1 Still, anything short of the most complete 
removal of the disease is entirely inadmissible. For suc- 
cess depends on the contact of the healthy surfaces, and 
incipient carious bone, if unremoved, will render the best 
efforts unavailing. Gouging, as a substitute for the saw, 
is, consequently, a questionable proceeding, and only ad- 
missible when it leaves behind a surface which bleeds at 
all points. It might well be made an established rule, 
that excision should never be commenced except as an 
exploratory operation, to be continued, or to give way to 
amputation, as circumstances should indicate. 



RESULTS OF EXCISIONS. 

Whether performed for injury, for deformity, or for dis- 
ease, it is to be remembered that useful and serviceable re- 
sults, as a rule, are never attainable in less than a year, and 
often not until even a longer period, after the operation. 
This slow convalescence is perhaps one of the most serious 
objections to the operation, and shows how desirable it is 
that the subjects of it should not be worn out by previous 
suffering, or of so advanced an age that the blood shall 
have lost those elements on which the success of repara- 

1 Blackman's Ed. of Velpeau's Elements of Op. Surg., Vol. II. p. 457. 



RESULTS OF EXCISIONS. 15 

tive processes depends. The importance, therefore, of a 
judicious choice between excision and amputation is en- 
hanced by other considerations than those belonging to 
the mere preservation of the limb ; for a patient may 
make a good recovery from an amputation, performed at 
the outset, when he would not survive an ill-advised ex- 
cision, much less an amputation required by its failure. 

Excisions are sometimes only partially successful ; and 
it cannot be kept out of sight, that many of these opera- 
tions, especially those performed on the lower extremity, 
the subjects of which were discharged from hospitals at 
the close of a long treatment in an apparently satisfac- 
tory condition, and with every promise of a useful limb, 
have ultimately proved failures, either from a return of 
the disease in the bones, the persistence and aggravation 
of sinuses and fistulae thought to be insignificant and un- 
important, the imperfect adaptation of the opposing bones, 
the gradual yielding of the union and the development of 
lateral curvature or angular deformity, the cessation of 
growth, or a variety of other causes not always to be 
anticipated, or even prevented. Many such results of 
cases operated on in the earlier days of excisions have 
been reported within the last year or two, and will again 
be referred to in the appropriate place. 

The deformity entailed by the operation of excision, 
even in the most successful cases, is by no means incon- 
siderable. 

In the upper extremity a considerable imperfection in 
the motions of the new false joint must occur. Where 
mobility is desired, and not anchylosis, as in the shoulder 
and elbow, it is only in rare and comparatively excep- 
tional cases that the bones become rounded and play 
smoothly upon each other; the flexibility of a ligamen- 
tous union, in all ordinary cases, giving the limited mo- 
bility attainable. 

In the lower extremity the shortening necessarily fol- 
lowing excision becomes a deformity which may be un- 



16 EXCISIONS IN GENERAL. 

important in the upper. This of course varies in degree ; 
a thick sole, or a high heel, may, in some instances, com- 
pensate for it very satisfactorily, but when it is " six or 
seven inches," or the deformity requires " the aid of a 
leather case at the knee," or " a boot propped up by two 
steel rods seven inches long," or such an appendage as 
that represented in a drawing accompanying the report 
of an excision of the knee performed by Dr. G. Buck of 
New York, 1 a doubt may arise, even if the unfortunate 
subjects are able to " work hard," whether an artificial 
limb would not be an improved substitute for so muti- 
lated a member. 

Whether later experimental researches will lead to a les- 
sening of these after-deformities remains to be seen. Some 
recent researches on the functions of the periosteum, and 
the artificial reproduction of bone, have made M. L. Oilier, 
of Lyons, sanguine enough to hope so. He says : " Dans 
une resection l'art ne doit plus se borner a enlever les par- 
ties altere*es, il doit aussi viser a faire reproduire les frag- 
ments osseux qu'il a sacrifie. La physiologie exp^rimen- 
tale nous en indique le moyen, elle nous apprend pourquoi 
les resections pratique*es jusqu'ici ont e*te si exceptionelle- 
ment suivies de regeneration et nous revele ce qu'il faudra 
a l'avenir. La conservation du perioste doit etre une in- 
dication de premier ordre. Dans un travail recent, (Des 
Moyen s Chirurgicaux de favoriser la Reproduction des Os 
apres les Resections, Paris, 1858,) nous avons cherche a 
etablir que, malgre des difficulte*s inhe'rentes a certains 
conditions anatomiques et physiologiques, cette indication 
etait toujours realisable, partiellement du moins, et nous 
avons demontre* que 1' observation clinique en avait deja 
pleinement confirme* la justesse." 2 

On the other hand, the experiments of Heine tend to 
show that it is only in the rarest cases that the deficiency 
of bone is replaced ; still more seldom that the mass of 

1 Am. Journ. of Med. Sc, Oct. 1845, p. 282. 

2 Journ. de Phys. de B. Sequard, Jan v. et Avril, 1859. 



RESULTS OF EXCISIONS. 17 

new bone possesses the form of that which was removed. 
The periosteum plays the principal part in this repair, 
but the reproduction takes place to some extent without 
it. The exudation necessary for the regeneration of bone 
appears to be furnished by all the tissues. 1 

The researches of M. Bourguet, 2 derived from clinical 
observation, and made since those of M. Oilier, confirm 
the opinions of Heine. 

The most frequent causes of fatal results after excis- 
ions* are either those common to all large operations, or 
those due to the age of the patient, or to the general con- 
stitutional state which accompanies the condition requiring 
interference. It is not probable that the time of operating 
has much influence on the issue. In military practice 
there is doubtless a choice in the time when operations for 
traumatic lesions should be performed ; but in civil prac- 
tice, and for disease, it is not so necessary to be governed 
by predetermined rules. In the latter it is the general 
and constitutional condition, more than the local one, 
which tells the surgeon — let the disease be just com- 
mencing or fast approaching a fatal termination — what 
is to be gained or lost by waiting ; whether the con- 
stitutional state existing — excited perhaps by the long- 
continued irritation of the local condition, rather than by 
a natural predisposition — may not rapidly improve on the 
removal of the exciting cause ; whether the long ensuing 
confinement can be borne, or whether it is altogether be- 
yond the reach of cure by operation. These are ques- 
tions not to be decided by any arbitrary rules. 

One cause of fatal and unsuccessful results deserves, 
however, to be specially mentioned. No fact connected 
with the history of excisions is better established than that 
such results generally follow partial operations, especially 
in the ginglymoid joints ; i. e. operations in which a por- 

1 On the Process of Eepair after Resection and Extirpation of Bones. By 
A. Wagner. New Syd. Soc, Vol. V. p. 156. 

2 Lancet, Aug. 25, 1860, p. 200. 

2* 



18 EXCISIONS IN GENERAL. 

tion of the articulating surface and synovial membrane is 
left untouched. Union does not readily take place between 
osseous and cartilaginous surfaces brought into apposition ; 
the cartilage almost invariably separates, slow exfoliation 
taking place ; and necrosis, or the disease for which the 
operation was undertaken, is very apt to be set up in the 
part remaining untouched. This contingency was long 
since alluded to by Mr. Syme 1 in the following words: 
" With regard to the cartilage, it might be expected that 
no harm could result from leaving any part of it t that 
remained sound ; but here too the judgment of theory is 
reversed by experience, since it has been found that, when 
any portion of the articulating surface was left, the disease 
required a subsequent operation. The cause of this is 
probably to be referred, not so much to any morbid pro- 
cess in the cartilage itself as in the synovial membrane 
lining it, and in the spongy bone immediately subjacent, 
which has its tendency to morbid action excited by the 
injury sustained in its neighborhood. The operation, 
therefore, requires the removal of the whole cartilaginous 
surface.'' 

Of the truth of this statement, the succeeding pages will 
afford abundant proof. 

The question has been raised whether excision was more 
frequently performed, and less successful, on the left side 
of the body than on the right. Of the 709 excisions of 
large joints for organic lesions, comprised in the tables 
contained in the following pages, 427 recovered, and 282 
resulted in death, amputation, or very incomplete success. 
The side is mentioned in only 311, viz. 152 right and 159 
left. Of the failures occurring in these 311 cases, 57 were 
of the left side and 48 of the right. Of 269 excisions for 
traumatic lesions, 207 recovered and 62 died.* The side 
is mentioned in only 95 cases, viz. 49 left and 46 right, 
and of 25 deaths occurring in these, 17 were of the left 

1 On Excision of Joints, (Edinburgh, 1831,) p. 19. 



RESULTS OF EXCISIONS. 19 

side and 8 of the right. These figures indicate, therefore, 
that there is but slight ground for considering the left 
side as more prone to disease or injury, or less fortunate, 
unless perhaps in traumatic cases, in the result of opera- 
tions performed upon it. 

The percentage of failure in these two classes of cases 
added together is 35.17. In Paul's table of 1128 excis- 
ions of all sorts, which includes many operations not en- 
titled to be classed as such, and where cases are enumer- 
ated over and over again, the rate of failure is 27.47 
per cent. 1 In a similar table collated by 0. Heyfelder, 
the percentage is 28. 82. 2 



In face of the facts which have accumulated, the pro- 
priety of excising joints cannot be gainsaid. As in all 
mooted questions, we find positions which are untenable 
assumed under the compulsion of controversy, party feel- 
ing, and rivalry ; common sense carried away by enthu- 
siasm ; and various agencies so influencing the motives of 
most of those who have yet written or expressed them- 
selves on the subject, that it well admits of being exam- 
ined afresh from an impartial point of view. 

The uncertainty which characterizes all excisions shows 
that there remains something yet to be learned. Mr. Fer- 
gusson remarks upon the singularity of the fact, " that out 
of the three cases (of excision of the knee-joint) he has 
operated on, the successful one was the worst, those who 
have not got well not having had so great an amount of 
disease in the joint as the one who recovered." 3 And a 
British medical officer says, in speaking of the wounds of 
joints in the Crimea : " In the management of no accidents 

1 H. J. Paul, Die conservative Chirurgie der Glieder, (Breslau, 1859,) p. 40. 

2 Operationslehre und Statistik der Resectionen, (Wien, 1861,) p. 395. 
8 Lancet, April 22, 1854. 



20 EXCISIONS IN GENERAL. 

was so much expected from modern improvements, and by 
none were we so much disappointed." 1 

At the present time, the value of a limb from which the 
joint has been excised, the comparative dangers of the 
operation, the joints to which experience shows it to be 
properly applicable, and the conditions of disease or inju- 
ry under which it may be performed, as well as the ex- 
tent and manner of operative interference, can all be es- 
timated better than ever before. 

Excision of the lower jaw seeming to constitute a dis- 
tinct subject, and that of articulations like the sterno- 
clavicular, acromioclavicular, costal, &c, being of such 
exceptional performance as to forbid appreciation, the 
consideration of the operation as applied to the joints of 
the extremities will alone be discussed in the following 
pages. 

1 Edinb. Monthly Journ. of Med. Sc, July, 1859, p. 67. 



EXCISIONS OF TIIE UPPER EXTREMITY. 

SHOULDER-JOINT. 



HISTORY. 

It has been claimed that M. Boucher, of Lille in France, 
after the battle of Fontenoy, which was fought May 11, 
1745, first introduced the practice of excision in place of 
amputation, by extracting through the wounds made by 
gun-shot injuries the fractured portions of the articular 
extremities of bones, and especially those entering into 
the formation of the shoulder-joint. 1 But, as Baron Percy 
justly remarks, the course adopted by this distinguished 
surgeon was unpremeditated, and he never contemplated 
laying down a law which only a few chance cures could 
sustain ; — like M. Jourdain, " II a fait de la prose sans 
le savoir." Indeed, the head of the humerus had been 
already removed in August, 1740, by M. Thomas, of Pe- 
zenas, in Languedoc ; the case, however, appears to have 
been one of necrosis, where an extraction of the dead 
bone was effected in the course of several operations, 
rather than by a regular excision. 2 

In April, 1768, Mr. Charles White, of Manchester, Eng- 
land, removed a large portion of the upper part of the 
humerus. Mr. White had previously excised the head 
of the bone in the dissecting-room, but this he claims to 

i Mem. de l'Acad. de Chir., Tom. II. p. 211. 

2 Mem. de l'lnst. Sc. Math. et. Phys., Tom. V. p. 367. 



22 EXCISION OF THE SHOULDER- JOINT. 

have been the first instance of the operation performed 
upon the living subject. His claim has been generally 
recognized, but the history of the case proves it to have 
been one of necrosis, and a glance at the engraving accom- 
panying the report shows very plainly that the head of the 
humerus remained unremoved in the glenoid cavity, the 
sequestrum, a portion of the shaft, having separated at the 
epiphysial junction. 1 The case itself is noteworthy, if on 
no other account, for the attention which it attracted, and 
as having led the way to nearly all which has since been 
accomplished in this department of surgery, no allusions 
to excision being complete without reference to it. 2 

The excision so often attributed to Vigaroux, of Mont- 
pellier, in 1767, is shown by a letter of his to Sabatier to 
have been an operation precisely analogous to that of Mr. 
White, the head of the bone having been left, retained in 
its place by the capsular ligament. 3 Of the case of Da- 
vid, of Rouen, referred to by Roux and Boyer as having 
occurred about the same time as those of White and Vi- 
garoux, I know nothing, except that it was first published 
in 1808 or 1804, the work in which it is detailed not 
being procurable. 4 

In April, 1770, the head of the humerus, separated 
from its shaft by an arthritic disease, the nature of which 
is not apparent from the description, was removed by Ride- 
wald. The operation was performed whilst the patient, a 
man fifty years old, was in a wretched condition, and the 
limb was finally amputated on account of suppuration 
and hemorrhage, and he died three weeks afterwards of 
hectic. 5 

In October, 1771, Mr. James Bent, of Newcastle, Eng- 

i Philos. Trans. Lond., Vol. LIX. p. 39. 

2 White's name is usually spelled by Continental writers " Withe," or 
" Whytt." 
8 Mem. de l'Inst. Sc. Math, et Phys., Tom. V. pp. 371-373. 

4 David (fils), Dissert, sur l'Inutilite de l'Amp. des Membres, etc. Paris, 
An XI. 

5 Wachter de Artie. Extirp., etc., (Groningen, 1810,) p. 68. 



HISTOKY. 23 

land, formally excised the head of the humerus for caries 
of three years' standing, with entire success. His account 
of the case was published in 1774, and it is undoubtedly 
the first authenticated instance of this operation for dis- 
ease, 1 although in the same year, according to the brief 
statement of Jaeger, it was also performed by a German 
named Lentin. 2 

In August, 1778, Mr. Daniel Orred, of Chester, per- 
formed, and in 1779 published the account of, a similar 
operation for caries, of three years' standing, in a man of 
forty. 3 

In July, 1786, the elder Moreau operated upon the 
shoulder-joint of a young woman from Cousance, remov- 
ing the head of the humerus, the glenoid cavity, and a 
portion of the acromion. The result was a remarkably 
successful one, and the case is the first in which complete 
excision was performed. 4 

Baron Percy, stimulated by the example of Moreau's 
operation, at which he assisted, excised the head of the 
humerus twice before 1789, and in 1794 showed to Sa- 
batier, then Professor of Surgery at Paris, nine soldiers 
who owed the preservation of their arms to this ex- 
cision, and who, as he says, " s'en servent maintenant 
pour exercer et cultiver des talens, soit utiles, soit agre- 
ables, ou pour subvenir a leur be'soins par des travaux 
plus penibles." In 1795, this surgeon had operated nine- 
teen times, 5 and at his instigation, " a short time after 
1794, a medal was granted by the Academy of Sciences 
to M. Fernire, of Moux, near Paris, as an honorary re- 
ward for a successful removal of the head of the humerus 
in a boy, aged fourteen, whose arm two of the most cele- 



i Philos. Trans. Lond., Vol. LXIV. p. 353. 

2 M. Jaeger. Operatio Resectionis conspectu chronologico adumbrata, (Er- 
langen, 1832,) p. 3. 

3 Philos. Trans. Lond., Vol. LXIX. p. 6. 

4 Jeffrey's Park and Moreau, p. 162. 

5 Diet, des Sc. Med., Art. Humerus. 



24 EXCISION OF THE SHOULDER-JOINT. 

brated surgeons in France at that time had recommended 
to be amputated at the joint." 1 

In 1812, Sabatier, Larrey, Willaume, and Bottin were 
successful operators in cases of gun-shot injury, as also 
was the younger Moreau for caries in two instances, and 
a third time in 1815. In succeeding years, the names of 
Textor, Roux, and Jaeger are found associated with equal- 
ly fortunate results. 2 

In 1826, Mr. James Syme, of Edinburgh, reported the 
details of an excision, and remarked that until then, since 
the time of Messrs. Bent and Orred, no British surgeon, 
so far as he knew, had recorded a single instance in 
which caries or other disease of the shoulder-joint had 
been cured by this means. 3 In July of the same year the 
above-named surgeon had a second case, and in fact, from 
the year 1812 onwards, the operation appears to have be- 
come an established one, performed with almost uniform 
success. 

In the United States, it was first practised for gun-shot 
wounds by Dr. William Ingalls, of Boston, in the winter of 
1812-13. The patient was a soldier in the United States 
army, and he recovered with a tolerably useful limb. 4 It 
was also performed by Drs. Brown, Walker, and Mann, 
surgeons attached to the American army, after the battle 
of Plattsburg, September 11, 1814 ; 5 and the first time for 
disease by Dr. Ninian Pinckney, U. S. N. ? January 6, 
1842. 6 

Excision of the shoulder-joint, usually only partial, has 
been performed for traumatic causes, and for disease. In 
cases of anchylosis the operation can hardly be considered 

1 Guthrie on Gun-shot Wounds, p. 464. 

2 Jaeger. Op. Kesect. consp. chron. adumb., p. 3. 

3 Edinb. Med. and Surg. Journ., Vol. XXVL, (1826,) p. 49. 

4 Communicated by an eyewitness of the operation. 

5 Medical Sketches of the Campaigns of 1812, '13, and '14, by J. Mann, 
(Dedham, 1816,) p. 208. 

6 Am. Journ. of Med. Sc, Oct. 1846, p. 331. 



EXCISION FOR INJURY. 25 

admissible, provided that be the only reason for doing it, 
since the mobility of the scapula and the range of motion 
in the fore-arm compensate so considerably for stiffness in 
the joint. Moreover, anchylosis of this articulation after 
disease is of extreme rarity, there being (in 1855) in the 
museums of London and Paris but four specimens illus- 
trating such a condition. 1 



EXCISION FOR INJURY. 

The advanced position of the soldier's shoulder, when 
in the act of firing, makes it an event of not infrequent 
occurrence for a bullet either to bury itself in the head 
of the humerus, or to traverse it without much comminu- 
tion, or, striking immediately below it, to break the bone 
short off. Under other circumstances, heavier projectiles, 
grape-shot, cannon-balls, and fragments of shell, lay open 
and fracture the joint, and carry away, perhaps, a por- 
tion of the deltoid muscle. In the Crimea, according to 
the French resumS, in open engagements, the superior 
extremity was wounded once in every 4.3, and in siege 
operations, once in every 6.2 of all wounds reported. 2 Of 
47 gun-shot wounds of the upper extremity, 28 were of 
the shoulder and arm. 3 



i Med.-Chir. Trans., Vol. XXXVIII. p. 95 ; Lancet, April 20, 1861. 

It appears, however, that the head of the humerus has recently been re- 
moved on account of a deformity, resulting from injury received during birth, 
which is described as anchylosis and " extreme rotation at the shoulder-joint, 
with the hand behind the back." The nutrition and innervation of the limb 
were impaired, and the patient could exert but little power in its use, though 
the scapula moved freely on the trunk. Under these exceptional circumstances 
the head of the bone was excised by Dr. Alfred C. Post, of New York. The re- 
sult of the case I am unable to give. (American Medical Times, Feb. 9, 1861 .) 

2 G. Scrive, Relation Med.-Chir. de la Campagne d'Orient, (Paris, 1857,) 
p. 443. 

3 Dublin Quarterly, Aug., 1859, p. 27. 

3 



26 EXCISION OF THE SHOULDER-JOINT. 

Not to particularize the cases susceptible of treatment 
by excision, it may be briefly said, that it is appropriate 
to all injuries of the shoulder-joint, where amputation 
would otherwise be necessary, which are not accompanied 
by too great destruction of the soft parts, or damage to 
the great vessels and nerves, and where the bone is not 
too much comminuted or splintered in the shaft. M. 
Baudens, one of the best modern authorities on this sub- 
ject, regards the indications for excision as absolute — 
excision the rule, and amputation the exception — in all 
injuries of the head of the bone by a ball, even when 
fracture extends to the diaphysis and into the medullary 
cavity. "In four cases," he says, "we were content to 
remove the head of the humerus, without minding the 
fissures which ran more or less down the shaft of the 
bone into the medullary cavity, and recovery took place 
just as if these fissures had never existed." 1 In the Schles- 
wig-Holstein campaign, so much as four to five inches of 
the shaft were removed with the head, and without detri- 
ment to the result. 2 

As gun-shot wounds are of so variable a character, inju- 
ries to the coracoid and acromion processes, to the clavicle, 
and more rarely to the body and neck of the scapula, will 
sometimes be found complicating that of the humerus. 
Although extensive fracture of the scapula destroys the 
probability of success (Stromeyer), fragments of it have 
been removed or left to exfoliate without essentially modi- 
fying the result, although considerably increasing the sup- 
puration and protracting the time of recovery. Complete 
excisions have been successfully done by Guthrie, Mann, 
Larrey, Lauer, Baudens, and others. Larrey's case 3 was 
remarkable for the extent to which bone was removed, 
(head of humerus, humeral end of the clavicle, and acro- 
mion process,) and for its recovery with considerable use of 

1 Translation in Amer. Journ. of Med. Sc, July, 1855, p. 242. 

2 Statham's Stromeyer and Esmarch, p. 65. 

3 Mem. de Chir. Milit., etc., (Paris, 1812,) Tom. II. p. 179. 



EXCISION FOR INJURY. 27 

the arm. Decapitation of the humerus is, however, alone 
required ordinarily. 

Sometimes only a portion of the head of the humerus 
need be removed. Such operations were practised in the 
Crimea. The after-mobility, it is said, was more restricted 
than when the whole extremity of the bone was taken 
away. 1 Unfortunate results do not, however, as a rule, 
seem to follow partial excision of this articulation, as they 
do in other joints. Yet a case of exfoliation of the gle- 
noid cavity, after removal of the head of the humerus, is 
mentioned by Larrey. 2 

The considerations already advanced render excision 
equally applicable to some cases of compound and of 
comminuted fracture of the neck of the humerus, as well 
as to compound dislocation, from other than gun-shot in- 
juries. 3 Mr. H. Hancock, of London, has also operated, 
a month after the accident, for a separation of the epi- 
physis from a blow. 4 The last-named accidents (com- 
pound dislocation and separation of the epiphysis) are of 
great rarity, and their treatment, therefore, is not amen- 
able to fixed rules ; moreover, in drawing inferences from 
military practice, it is to be remembered that its exigencies 
often require operative interference of a grave character, 
where in civil practice more temporizing measures might 
be adopted. Although a shattered head of the humerus 
may recover without operation, it is claimed by many, 
(Esmarch, Petruschky, Kyriakos,) that more rapid and 
better results, to say nothing of greater safety, follow ex- 
cision, than the gradual exfoliation of fragments ; that 
the time required, and the condition left, by the slow 
processes which accompany the latter course, are more 
unlikely to give a useful arm. As the operation can be 
performed with equal if not greater success after the 
establishment of suppuration, a certain amount of delay, 

1 Macleod, op. cit., p. 332. 

2 Loc. cit. 

3 Hamilton, Treatise on Fract. and Disloc., p. 723. 

4 Lancet, July 6, 1850. 



28 



EXCISION OF THE SHOULDER-JOINT. 



even beyond that period, will hardly interfere with the 
character of its results. 

Comparatively rapid recovery follows excision for in- 
jury. Soldiers, in several instances of its performance in 
the Schleswig-Holstein campaign, in the Crimea, and the 
last Indian mutiny, returned to their regiments, or to a 
modified duty, before the end of the war. 1 The soft parts, 
being in a healthy condition, take on reparative action 
readily, and it is only deferred by the presence of some 
foreign body in the wound, exfoliation, or the irritation 
of a detached but unremoved fragment of bone. Instances 
are recorded of recovery in two and three months; 2 but 
this probably means that the patients were discharged 
from treatment at the end of that period, the full useful- 
ness of the arm not being obtained in less than twelve 
months, or even more. 

The mortality of this excision is shown by the follow- 
ing tables, which certainly do not justify the remark of 
Hennen, that it is an operation " more imposing in the 
closet than applicable in the field." 3 

Primary Operations. 



Reporter's Name. 



Larrey, 

Baudens( Crimea), 

Guthrie, 

Legouest, 

Esmarch, 

Macleod, 

Williamson, 

Stratton, 

Hello, 

Mann, 

Gorre, 

Bryce, 

Eve, 



No. of 


No. of 


Cases. 


Deaths. 


10 


4 


11 


1 


2 


1 


6 


4 


6 


2 


8 


1 


1 





1 





1 





3 





1 


1 


2 


1 


1 


1 


53 


16 



Authority. 



Mem. de Chir. Milit, Tom. II. p. 175. 
Am. Journ. of Med. Sc., July, 1855, p. 243. 
On Gun-shot Wounds, p. 468. 
Arch. Gen. de Med., Avril, 1859, p. 463. 
Statham's Translation, p. 68. 
Surgery of the Crimean War, p. 328. 
Dublin Quarterly, August, 1859, p. 80. 
Edinb. Med. & Surg. Journ., Jan. 1846, p. 31 
Philad. Med. Exam., Vol. IV. p. 739. 
Sketches of the Campaigns of 1812, '13/14. 
Malgaigne, Tr. des Luxations, p. 558. 
Lancet, Sept. 10, 1830. 
Am. Med. Times, July 21, 1860. 



1 T. Petruschky, De Resectione Articulorum Extremitatis superioris, (Bero- 
lini, 1851,) p. 2 ; Statham's Stromeyer and Esmarch, p. 65 ; Dublin Quarterly 
Journal, (Aug., 1859,) p. 81. 

2 P. G. Kyriakos, De Articuli Humeri et Cubiti Resectione, (Berolini, 1854,) 
p. 6. 

3 Principles of Milit. Surg., 3d ed., (London, 1829,) p. 40. 



EXCISION FOR INJURY. 



29 



Secondary Operations. 



Reporter's Name. 


No. of 
Cases. 


No. of 
Deaths. 


Esmarch, 


13 


5 


Baudens( Crimea), 


3 





Williamson, 


2 





Macleod, 


5 





Guthrie, 


6 





Baddely, 


1 





Beith, 


1 





Hevfelder, 


1 


1 


Hancock, 


1 





Waters, 


1 

34 







6 



Authority. 



Statham's Translation, p. 68. 

Am. Journ. of Med. Sc, July, 1855, p. 243. 

Dublin Quarterly, August, 1859, p. 81. 

Surgery of the Crimean War, p. 328. 

On Gun-shot Wounds, p. 468. 

Am. Journ. of Med. Sc., April, 1843, p. 467, 

Lancet, February 23, 1856. 

Operationslehre, u. s. w., p. 211. 

Lancet, July 6, 1850. 

N. Y. Journ. of Med., May, 1847, p. 318. 



Uniting these two series of cases, and adding to them 
six operations with three deaths performed by M. Baudens 
in Algiers, 1 and three others, successful, (one by Langen- 
beck and two by Textor, 2 ) of which it is unknown whether 
they were primary or secondary operations, we have a 
total of 96 cases, with 25 deaths, or a mortality of 26 
per cent. Comparing the above result with the statistics 
of amputation at the shoulder-joint as derived from Cri- 
mean experience, 3 from which we learn that, of 60 oper- 
ations, 19, or 31.6 per cent, were fatal, we have a result in 
favor of excision of 5.6 per cent. 

" It is curious," says Esmarch, " that the operation on 
the left side seems to give less favorable results than on 
the right ; 6 out of 12 died of those resected on the left, 
and 1 out of 7 of those resected in the shoulder, on the 
right side. A similar proportion held good in resection 
of the elbow ; for of those operated upon on the left, 4 in 
19, on the right, 2 in 20, resections proved fatal. From 
this, the fatality attending operations on the left arm to 
that on the right is as three to one ; but," he justly adds, 
" further observations are required to enable conclusions 
to be deduced." 4 



1 Lond. Med. Gaz., Oct. 20, 1838. 

2 Arch. Gen. de Me'd., 5 me serie, Tom. II. p. 714. 

3 Macleod, op. cit., p. 389. 

4 Statham's Stromeyer and Esmarch, p. 68. 

3* 



30 EXCISION OF THE SHOULDER- JOINT. 

In the cases which I have myself collected, mention is 
so seldom made of the side injured, whether left or right, 
that I am unable to add anything in confirmation of or 
against the preceding statement. 

Secondary excisions are not followed by the mortality 
usually supposed to attend them. Such a conviction had 
been established in my own mind before I learned that 
the experience of the surgeons in the Schleswig-Holstein 
war had led them to the same conclusion. By the pre- 
ceding tables it appears that in 53 primary operations 
there were 16 deaths, or a mortality of 30.18 per cent, 
and in 34 secondary operations 6 deaths, or a mortality 
of 17.64 per cent, being 12.54 in favor of the latter. 

This fact is made particularly apparent by Esmarch, 
who reports that of 6 excisions of the head of the hume- 
rus performed within 24 hours of the injury, 2 died. Of 
3 during the inflammatory stage, or on the third or fourth 
day, 2 died ; and of 10 after suppuration was established, 
2 died. Of 8 cases suited for excision and which were 
left to nature, not being operated on, owing to insufficient 
experience of the value of. excision, 5 died, and the re- 
maining 3, at the end of six months, still seemed to need 
operative interference. 1 

" Of 26 patients in the ambulances of M. Baudens, 11 
immediate excisions were performed with 10 recoveries. 
From their injuries seeming less grave, 15 were treated 
by expectation ; of these, 8 died of purulent infection, 3 
underwent consecutive resection with success, and 4 suf- 
fered a long train of ill consequences from fistulous open- 
ings." 2 Though this is rather negative testimony, still it 
will be observed that all the secondary operations had a 
favorable termination. All those, also, which appear in the 
English Crimean returns were equally successful. 3 

It is probable that the greater success of secondary op- 

1 Statham, loc. cit. 

2 Am. Joura. of Med. Sc, July, 1855, p. 243. 

3 Macleod, op. cit., p. 331. 



EXCISION FOR DISEASE. 31 

erations is due to the fact, that it is the less grave inju- 
ries which are reserved for expectant treatment ; and that 
after the lapse of time and the establishment of suppura- 
tion, the exact extent of the injury, as to fissures, frac- 
ture, injury to the periosteum, etc., can be determined in 
a manner not always easy to effect at the time of the 
accident. In the one case, all which should be is re- 
moved, in the other, the operator may fall short of the 
proper limits. 



EXCISION FOR DISEASE. 

Excisions of the shoulder-joint have been performed for 
caries and necrosis, as well as for malignant and non- 
malignant tumors or affections, which by their extension, 
or rapidity of progress, promise either to render any op- 
eration impracticable, or require the removal of the limb 
at the articulation. 

Excision for malignant disease is, as might be expected, 
attended by no encouraging success ; perhaps even with 
less than amputation. Roux removed the head of the 
humerus for an osteo-sarcoma, and the patient died shortly 
afterwards. 1 Mr. J. Hutchinson excised the head and 
upper fifth of the humerus on account of a large myeloid 
tumor, developed within the bone, and death occurred 
from recurrent disease in the lungs and elsewhere before 
the usefulness of the limb had been put to much trial. 2 
Another similar operation, by the same surgeon, was 
equally unsuccessful, the disease recurring and death en- 
suing from hemorrhage four months after its performance. 3 



1 London Med. Gaz., Sept. 13, 1834. 

2 Med. Times and Gaz., Aug. 20, 1859. 

3 Ibid., Nov. 1, 1856. 



32 EXCISION OF THE SHOULDER-JOINT. 

Mr. Bickersteth, of Liverpool, has successfully excised 
the head of the humerus for an exostosis. 1 

Upon two occasions Dr. Daniel Brainard, of Chicago, 
has opened the shoulder-joint for removal of the head of 
the bone, on account of the suppuration resulting from 
severe injuries ; in one case a year after, and in the other 
three months after the receipt of the injury. The head 
of the bone in each instance was loose, necrosed, and partly 
absorbed or macerated. Both patients recovered with tol- 
erably useful arms. 2 Two somewhat similar instances, 
where the heads of the bones were spontaneously dis- 
charged, the parts rapidly healing, are cited by Black- 
burn 3 as having occurred to Sabatier. 

Schillbach reports the case of a boy, sixteen and a half 
years old, from whom, at the inner and back part of the 
head of the humerus, a sequestrum, the size of a quarter- 
dollar and two and a half lines thick, was removed by en- 
larging in different directions the fistulse to which it had 
given rise. The rest of the joint was healthy, excepting 
in one other spot, where a small fragment was extracted. 
After the operation, the infiltration and swelling soon 
disappeared, and in twenty-five days the patient had full 
use of the arm. 4 

It is, however, to cases of " white-swelling," where the 
shoulder-joint becomes disorganized by disease of the sy- 
novial membrane, by ulceration of the cartilages, or caries 
of the bone, that excision is especially applicable. 

It is a notable fact, that this articulation is less fre- 
quently thus affected than any other of the large joints of 
the body ; according to the records of Guy's Hospital, in 
only one per cent of all the cases of diseased joints. 5 A 
rather insufficient explanation of this immunity has been 



1 Lond. and Edinb. Month. Journ. of Med. Sc, June, 1853. 

2 Hamilton, Treatise on Disloc. and Fract., p. 217. 

3 Guy's Hosp. Rep., April, 1836, p. 274. 

4 Beitr. zu den Resect, der Knoch., (Jena, 1859,) p. 130. 

5 Bryant, Dis. and Inj. of Joints, p. 136. 



EXCISION FOR DISEASE. 33 

offered by suggesting that the synovial capsule, being cov- 
ered externally by the very dense and non-vascular ten- 
dons of the scapular muscles, is thereby indisposed to 
propagate and keep up an inflammation. 1 It is also a 
peculiarity of this joint, that disease ordinarily confines 
itself to the head of the humerus, without involving the 
opposite articular surface. In but 17 of the 50 cases of 
this excision which I have collected, did the glenoid cav- 
ity require to be interfered with. 

The infrequency of disease of the shoulder-joint is also 
shown by the comparative infrequency of its excision. The 
table on pages 34 and 35 comprises all the instances of its 
performance which a thorough search enables me to find. 

Of the 50 cases there enumerated, 34 were males and 
12 females, the sex not being stated in 4. In 14 the ex- 
cision was of the right arm, in 12 of the left, in 24 the 
side not being stated. In 42 recovery took place, and in 
8 there was a fatal result ; but two of those classed as re- 
coveries died of phthisis at the end of a year, and two oth- 
ers were not particularly benefited by the operation. It 
appears, therefore, that 16 per cent of all the cases were 
fatal, and 24 per cent unsatisfactory in their results. Of 
the unsuccessful operations, 4 were upon the right arm, 3 
upon the left, and in 5 the side is not mentioned. 

The deaths occurred at the expiration of 1 year, 6 
months, 5 months, 3 months, 6 weeks, 3 weeks, and 2 
weeks ; in one case the time which elapsed not being 
stated. Three were from phthisis, two from exhaustion, 
one from diarrhoea, one from ursemic poisoning, and in 
one the cause is not reported. 

In these eight fatal cases, there is but a single instance 
of partial excision ; with this exception, in every case 
where death followed, the glenoid cavity had been either 
gouged, excised, or cauterized. The reason of this ex- 
ception to a general rule is not apparent, unless it is that, 
the weight of the arm separating the end of the hume- 

1 Bonnet, Mai. des. Artie, Tom. II. p. 570. 



34 



EXCISION OF THE SHOULDER-JOINT. 





Sex. 


Age. 


Extent of Excision. 


Termination. 
Recovered. 


1 


M. 


17 


R. arm ; one third of head of humerus. 


2 


F. 


38 


L. arm ; head of humerus ; end of acromion. 


" 


3 


M. 


40 


L. arm ; head of humerus, coracoid process and 
glenoid cavity gouged. 


Died. 


4 




5 


Head of humerus. 


Recovered. 


5 


M. 


13 


R. arm ; head of humerus. 


" 


6 


F. 


46 


R. arm ; head of humerus. Glenoid cavity gouged. 


<< 


7 


F. 


25 


Large part of head of humerus. 


n 


8 


M. 


17 


L. arm ; head of humerus. Glenoid cavity 
gouged ; subsequently, a piece of the shaft. 


" 


9 


M. 


57 


R. arm ; head of humerus. 


K 


10 


M. 


35 


L. arm ; head of humerus. 


tt 


11 


M. 


25 


Head of humerus. Glenoid cavity gouged. 


Died. 


12 


M. 


35 


R. arm ; head of humerus. 


Recovered. 


13 


F. 


27 


Head of humerus. 


« 


14 


M. 


60 


R. arm ; head of humerus. 


Died. 


15 


F. 




R. arm ; head of humerus. 


Recovered. 


16 


M. 


40 


Head of humerus. 


<( 


17 


F. 


45 


L. arm ; head of humerus ; external angle of 
scapula ; part of acromion process. 


u 


18 


M. 


19 


L. arm ; head of humerus. Glenoid cavity gouged. 


tt 


19 


M. 


19 


L. arm ; head of humerus. Glenoid cavity gouged. 


a 


20 


M. 


14 


L.arm ; head and 5| in. of humerus. 


tt 


21 


M. 


60 


Head of humerus and glenoid cavity. 


tt 


22 


M. 


28 


L. arm ; head of humerus. 


tt 


23 


M. 


37 


R. arm ; head of humerus. 


it 


24 


M. 


65 


R. arm ; head of humerus and glenoid cavity. 


Died. 


25 


M. 




Head of humerus. 


Recovered. 


26 


F. 


19 


R. arm ; head of humerus. 


«< 


27 


F. 




R. arm ; head of humerus and glenoid cavity. 


Died. 


28 


M. 


34 


R. arm ; head of humerus. 


Recovered. 


29 


F. 




Head of humerus. 


(< 


30 


M. 


25 


Head of humerus. 


u 


31 


F. 


29 


Head of humerus. Glenoid cavity gouged. 


Died. 


32 


F. 


10 


Head of humerus. 


Recovered. 


33 


M. 


40 


Head of humerus. 


<< 


34 


M. 


24 


Head of humerus. 


" 


35 






Head of humerus. Glenoid cavity cauterized. 


Died. 


36 


M. 


40 


Head and 4 in. of humerus. 


Recovered. 


37 


M. 




R. arm ; head of humerus. 


tt 


38 






Head of humerus. 


tt 


39 


M. 


39 


L. arm ; head of humerus. Glenoid cavity gouged. 


Died. 


40 


M. 


28 


L.arm; head of humerus. Glenoid cavity gouged. 


Recovered. 


41 


M. 


13 


Head of humerus. 


<( 


42 


M. 


25 


L. arm ; head of humerus. 


it 


43 


M. 


39 


Head of humerus. Glen. cav. and neck of scapula. 


it 


44 


M. 


20 


Head and upper third of humerus. 


tt 


45 


M. 


15 


Head and upper third of humerus. 


tt 


46 


M. 


29 


Head of humerus. 


" 


47 


M. 


5 


R. arm ; head and I in. of shaft. Glen. cav. gouged. 


a 


48 






Head and 4 in of humerus. 


tt 


49 


M. 


20 


Head of humeru*. Glenoid cavity gouged 


it 


50 


F. 


18 


Head and large portion of shaft of humerus. Gle- 
noid cavity gouged. 


« 



EXCISION FOR DISEASE. 



35 



Length of 
Treatment. 


Ultimate Result. 


Authority. 


3 mos. 


Does duty as a sailor. 


Am. Journ. of Med. Sc, Oct. 1846. 


2 mos. 


Sews, knits, washes 


Syme, Excis. of Dis. Joints, p. 51. 


6 mos. 


Death from phthisis. 


Ibid., p. 58. 


2 mos. 


" Pretty good use of limb." 


Am. Journ. of Med. Sc, Oct. 1857. 


6 weeks. 


Useful arm. 


Diet, des Sc. Med., T. 47, Resection. 


5 weeks. 


Very useful arm. 


Med.Times & Gaz., Nov. 26, 1859, and 
Lancet, Feb. 25, 1860. 




" Complete use of the arm." 


Fergusson's Pr. Surg., 3d ed., p. 308. 


1 year. 


" Extremely useful arm." 


Lancet, Dec. 11, 1852, and Erichsen's 
Sc. and Art of Surg., 3d ed., p. 702. 


18 mos. 


Works as a farm-laborer. 


Lancet, Aug. 25, 1855, & M. Chir. Tr., 


8j mos. 


Very useful arm. 


Lancet, Mar. 4, 1854. [Vol. 42. 


6 weeks. 


Death from uremic pois'ng. 


Med. Times and Gaz., Mar. 31, 1855. 


10 mos. 


Very useful arm. 


Lancet, Mar. 8, 1851. 


2 mos. 


Useful arm. 


Ibid., Mar. 4, 1854. 


2 weeks. 


Death from diarrhoea. 


Lancet. Sept. 12, 1857. 


9 weeks. 


Very useful arm. 


Philos. Trans. Lond., Vol. 64, p. 353. 


3 mos. 


Not a very useful arm. 


Ibid., Vol. 69, p. 6. 


4 mos. 


Useful arm. 


Jeffray's Park and Moreau, p. 162. 


4 mos. 


Useful arm. 


Lancet, Feb. 25, 1860. 


6 mos. 


" Not relieved." 


Mass. Gen. Hosp. Records. 


3 mos. 


Tolerably useful arm. 


Med. News and Library, Aug. 1851. 


3 mos. 


Weaves ten hours a day. 


Bost. Soc. for Med. Imp., Vol. I. p. 335. 


2 mos. 


Beginning to use the arm. 


Philad. Med. Ex., Vol. IV. p. 306. 


25 days. 


Died of phthis. at end of a yr. 


J. F. Heyfelder, ueber Resect., p. 131. 


21 days. 


Death from exhaustion. 


Ibid., p. 133. 


8 mos. 


Died of phthis. at end of ayr. 


New Sydenham Soc, Vol. V. p. 229. 




Moves arm in all directions. 


Lancet, Mar. 22, 1856. 


5 mos. 


Death from phthisis. 


Med. Times and Gaz., Feb. 4, 1860. 


9 mos. 


Very useful arm. 
Some motion ; fore arm very 
useful. Died of phthisis 5 


Med.-Chir. Trans., Vol. 42, p. 1. 




years after operation. 


Trans. of N. H.Med. Soc, 1859, p. 47. 




Fair amount of motion. 


Med. Times and Gaz., May 8, 1858. 


3 mos. 


Death from phthisis. 


Ibid. 




Useful arm. 


Ibid., Aug. 1, 1857. 




Useful arm. 


Ibid. 


6 weeks. 


No details. 


Ibid., Aug. 20,1859. 




No details. 


Blackman's Velpeau, Vol. II. p 474. 




Most satisfactory result. 


Gross. Syst. of Surg , Vol. II. p. 1087. 


1 month. 


Very useful arm. 


Arch. Gen.de Med., [2.] T. 5, p. 156. 




Most of the motions pre- 


Brit. &For. Med. Chir. Rev., Apr. 1851, 




served. 


p. 299. 


1 year. 


Caries and exhaustion. 


Schillbach, Resect.der Knochen,p. 141. 


3 mos. 


Movements tolerable. 


Ibid., p 149. 


10 weeks. 


No details. 


Glasgow Med. Journ., Oct., 1856. 


4 mos. 


" As good use as ever." 


N. Orleans M. and S. Journ., Jan. 1861. 


3 mos. 


Useful arm. 


Lond. Med. Gaz., Aug. 1845. 


14 days. 


In a year did heavy manual 


N. Am. Med.-Chir. Rev., May, 1858, 




labor. 


p. 557. 


14 days. 


Works as a farm-laborer. 


Ibid. 


3 weeks. 


Useful arm. 


Ibid. 


2 mos. 


Useful arm. 


Western Lancet, Aug. 1857, p. 551. 




Excellent result. 


O. Heyfelder, Operationslehre, p. 221. 




Considerable range of mo- 






tion obtained. 


Med. Times and Gaz., Apr. 27, 1861. 




No details. 


Ibid. 



36 EXCISION OF THE SHOULDER-JOINT. 

rus from the glenoid cavity, union by apposition does not 
take place, as in most excisions, and the incongruous 
rapprochement of a cartilaginous and osseous surface, 
which seems to be one of the chief difficulties in other 
partial operations, is thus prevented. That the train of 
consequences usually to be feared under such circum- 
stances may occur, seems to be shown by the remarks of 
Dr. Crosby, of Manchester, N. H., in the report of a case 
operated on by him, and where two or three openings 
continued to discharge during the five years which the pa- 
tient survived. " It may be asked," he observes, " why 
the wound did not entirely heal ; I can only say, that it 
is possible that the articulating surface of the scapula had 
become diseased after the operation, although it appeared 
perfectly sound at the time." 1 

The youngest subject of the operation in the foregoing 
table was 5 (2 cases), and the oldest 65 years of age. The 
first two lived, both regaining tolerably useful limbs ; the 
last died of exhaustion at the expiration of three weeks. 
The average age of those who recovered, where this is 
stated, is 27|f years, of those who died, 43 years. 

With regard to those cases in which recovery took place, 
it may be said that, apart from the preservation of the 
hand and fore-arm, no excision leaves so satisfactory re- 
sults with so little danger to life and so little demand for 
that constant supervision which other excisions require. 
The occurrence of anchylosis is extremely rare, and when 
it does happen, as has been already stated, it is compen- 
sated for by the mobility of the scapula. Guthrie relates 
a case where it took place, and yet the limb retained so 
much motion, " from the range of the scapula, as to enable 
the patient to put on and take off his clothes, tie his hand- 
kerchief, use his knife and fork, and perform many other 
operations of comfort and convenience." 2 The articulation 
usually becomes a sort of ginglymoid, instead of an enar- 

1 Trans, of the New Hampshire Med. Soc, 1859, p. 47. 

2 On Gun-shot Wounds, p. 476. 



EXCISION FOR DISEASE. 37 

throdial one, rotation being lost by the division of the mus- 
cles inserted into the tuberosities of the humerus. The 
limb has a certain swing or pendulum-like motion, and the 
power of lifting it from the side is limited. Dr. Paul F. 
Eve reports a case where, in six months after an excision 
for gun-shot injury, the arm could be raised to a level 
with the clavicle, 1 but the extent to which it can usually 
be lifted seldom exceeds five to eight inches. The move- 
ments of the hand and fore-arm are rarely impaired. A 
certain amount of shortening always ensues. The great- 
est removal of bone in any case appears to have been 5| 
inches (No. 20), and this was done without by any means 
destroying the usefulness of the limb ; for, though the 
movements of the scapula were lost, those of the fore-arm 
and hand remained intact. Mr. Bent's patient (No. 15) 
was able to sew, knit, and dress herself; others resumed 
their occupation, such as that of engineers, farm-laborers, 
weavers, sailors, etc., and the frequent report (evincing 
perhaps more enthusiasm than careful observation) is, 
that all the necessary movements of the limb, which do 
not require too great an elevation of the elbow, are per- 
formed with the same facility as by that of the opposite 
side. 

It is impossible to compare these results with those of 
amputation at the shoulder-joint, the performance of which 
for non-malignant disease is of rare occurrence. The 
advantage, however, does not lie in any diminution of the 
danger, for the mortality is probably about the same, — 
disarticulation not being a very fatal operation, — but in 
the preservation of a limb retaining more or less of its 
usefulness. 

1 Nashville Journ. of Med. and Surg., July, 1860. 



38 EXCISION OF THE SHOULDER-JOINT. 



OPERATION AND AFTER-TREATMENT. 

A great variety of methods of performing the operation 
of excision of the head of the humerus, or of the whole 
articulation, have been described. Formal incisions will, 
however, often be modified by the sinuses and fistulse, or 
wounds of the soft parts, if the case be a traumatic one, 
which may already exist. 

When applicable, the operation practised by Baudens 1 
is unquestionably the preferable one, on account of its 
simplicity, and because it obviates dividing the fibres of, 
and cicatricial deposits in, the deltoid muscle, though these 
perhaps are minor considerations. 

A straight incision, commencing as high as the acro- 
mion and just external to the coracoid process, where it 
can be carried higher than elsewhere, the point of the 
knife penetrating to, and keeping in contact with, the 
bone, is prolonged downwards along the anterior aspect 
of the joint, the head of the bone being more superficial 
at this than at any other part. The incision thus made 
corresponds to the bicipital groove containing the long 
head of the biceps muscle, which, according to Langen- 
beck, it is desirable to preserve undivided, whenever pos- 
sible. 2 This tendon being held to one side, the groove 
serves as a guide to the insertion of the four muscles at- 
tached to the tuberosities of the head of the humerus. 
Rotation outward, putting it upon the stretch, permits 
the division of the tendon of the internal muscle, and ro- 
tation inward exposes and allows the easy section of those 
belonging to the external muscles. The section of these 
opens the capsule which, in a great measure, they form. 
The hea'd may then be tilted from its socket, and the bone 
sawed across. 

Thickening and induration of the soft parts by dis- 

1 Trans, of Memoir in Am. Journ. of Med. Sc, July, 1855, p. 242. 

2 Petruschky, op. cit., p. 23. 



OPERATION AND AFTER-TREATMENT. 39 

ease may, however, prevent the articulating surface from 
being made accessible without prolonging a straight incis- 
ion to too great an extent, even though the fibres of the 
deltoid be divided transversely on each side without in- 
cluding the integument, as Baudens suggests. If, there- 
fore, some different method must be selected, the forma- 
tion of a crescent-shaped flap, as in the exarticulation 
called " Dupuytren's," will be found as advantageous as 
any other of the numerous incisions which might be de- 
scribed. 

It is always desirable to cut off the head of the hume- 
rus within the capsule, not only to diminish the amount 
of shortening necessarily ensuing, but that the posterior 
circumflex artery, a vessel of large size, and the circum- 
flex nerve, both of which pass close to and just below the 
head of the bone to be distributed in the deltoid muscle, 
may be respected. Whatever mode of operating is adopt- 
ed, however, and whether or not these are divided, the 
deltoid is sure to become atrophied after the operation, if 
it has not already become so through disuse, or by the 
unhealthy condition developed in the soft parts. 

The section of the bone may be made by the chain-saw 
or the common saw, the soft parts being protected by a 
spatula passed behind it. In cases of fracture of the 
neck, and where the head cannot be turned out of its 
place, nor be rotated as directed above, it must be seized 
by strong forceps and removed as we best may. In such 
cases it is not necessary to do more than cut off the sharp 
edges and irregularities of the shaft of the bone. It is to 
be remembered that the shaft of the humerus, when in 
an unhealthy state, may be easily broken by the operator 
in tilting the head outwards. An accident of this kind 
occurring to so skilful and experienced an operator as 
Mr. Stanley of St. Bartholomew's, is sufficient evidence 
of the necessity for being forewarned of its liability to 
happen. 

The glenoid cavity, if diseased, may be cut away with 



40 EXCISION OF THE SHOULDER-JOINT. 

the bone forceps, or gouged, as the case may require. 
The acromion and coracoid processes, though not enter- 
ing into the formation of the shoulder-joint, sometimes 
participate in the disease, and then require removal like 
other parts concerned. In the present state of surgical 
science, the application of the actual cautery for the cure 
of caries unremoved by the operation cannot be consid- 
ered as a judicious measure. 

Allusion has been made to a recommendation, that di- 
vision of the long tendon of the biceps muscle should be 
avoided. The preservation of this tendon is not probably 
a point of any great importance, unless in excisions for a 
traumatic cause, when it may generally be saved without 
difficulty, and perhaps with advantage. The experiments 
of Wagner, who excised the head of the humerus in forty- 
five rabbits, led him to attach very considerable impor- 
tance to its preservation. 1 In disease it is usually de- 
stroyed, or at all events rarely seen during the operation, 2 
and Esmarch, although strongly advocating its preserva- 
tion, remarks, that the unimportance of the step " was 
shown in three cases where the tendon had been torn across 
by the ball, yet, on the cure being completed, the patients 
very soon obtained free and voluntary use of the arm." 3 

Mr. Fergusson reports a single case in which he gouged 
out the carious head of the humerus through a simple 
opening made in the capsular ligament, and the patient 
regained " complete use of the arm." " The proceeding," 
he says, "was entirely novel in its character." 4 But the 
Chevalier Bernardino Larghi, of Turin, had already, in 
February, 1848, performed several operations of the sort, 
and cites Blandin as having imitated his example. 5 

1 On the Process of Repair after Resection, &c. New Syd. Soc, Vol. V. 
p. 168. 

2 Med. Times and Gaz., Nov. 5, 1859. 

3 Statham's Stromeyer and Esmarch, p. 67. 

4 Pract. Surg, 3d ed., (Lond.,) p. 308. 

5 Giornale delle Scienze Mediche di Torino. Ranking's Abstr., 1848, p. 118. 



OPERATION AND AFTER-TREATMENT. 41 

More recently, M. Se'dillot, of Strasbourg, has proposed 
as his own this very operation of scooping out the diseased 
extremities of bones (Svidement des os) in place of excis- 
ing them, in order, as was the object of his predecessors, 
to preserve the periosteum. On the 31st of October, 1859, 
he brought to the notice of the French Academy of Sci- 
ences ten cases thus operated on, of which three had died, 
one of phlegmonous erysipelas, the others at the end of 
several months, from causes, as he states, " in no way con- 
nected with the method pursued." Most of the patients 
had been subsequently seen, and found to be in a very 
satisfactory condition. 1 These operations included cases 
where the condyles of the femur and the head of the tibia 
were thus gouged out, and the external surface of the 
bone left intact. Two additional successful cases are re- 
ported by Messrs. Marmy of Lyons, and Ehrmann of Con- 
stantine. 2 

If the difficulties in the way of exact diagnosis, as well 
as the usual condition of joints which justify operation, are 
remembered, it will be seen that the cases to which this 
method can be made applicable must be of rare occurrence. 
Moreover, it would seem that M. Sedillot's confidence in 
his new method has been short-lived, since in the Lancet 
of August 24, 1861, we find him virtually condemning it 
on account of its frequent liability to failure ; suppuration, 
according to his experience, destroying the bone-making 
function of the periosteum. 

The treatment subsequent to the operation of excising 
the shoulder-joint is of the simplest character, and hardly 
requires any formal description. Nothing should be done 
to restrain motion, further than is necessary to prevent 
irritation or displacement. The tendency of the pectora- 
lis and teres major and of the latissimus dorsi to draw the 
extremity of the humerus inward, is to be prevented by a 

1 Arch. Gen. de Med., Dec. 1859, p. 748. 

2 L'Union Medicale, Nov. 29, 1859, p. 425. 

4* 



42 EXCISION OF THE SHOULDER-JOINT. 

cushion in the axilla. Besides this, repose, with the shoul- 
der and arm supported on a pillow for the first few days, 
and subsequently a sling and gentle compression with a 
bandage, to facilitate the discharge of matter, or to prevent 
it from burrowing down the arm, and the earliest use of 
passive motion, constitute nearly all which can be re- 
quired. 

The wound is generally very nearly healed at the end 
of a few weeks, but one or more sinuses sometimes con- 
tinue discharging for months, or even a year, and small 
portions of bone occasionally come away, but without hin- 
drance to the regaining of a useful limb. 

The average length of time before some use of the limb 
was commenced, as calculated from 31 of the cases in my 
table in which the period is stated, was lllff days, or 
over four months ; a much longer period than this was 
required, however, to elapse before it could be said to have 
become really serviceable. 

As an example of rapid recovery, and for the character- 
istic style of the narrative, the following account may be 
quoted from an article by Percy and Laurent. " L'un 
de nous fournit en '1789 un bel exemple de l'ablation de 
la tete de 1'humerus, a 1'Academie Royale de Chirurgie, 
a l'une des stances de laquelle il pre'senta un petit garcon 
de treize ans, lequel, tenant de sa main droite la tete de 
son humerus du meme cote qu'elle lui avait enlevee six 
semaines auparavant par le chirurgien major du regiment 
de Berri, cavalerie, en fit homage a la compagnie, que la 
conduite et l'esprit naturel de cet enfant interessaient 
presque autant que la piece, quoique tres r&re, dont il 
faisait don." 1 

According to Larrey, the chances of anchylosis are in 
proportion to the rapidity of cure. The early use of pas- 
sive motion and the observance of hygienic rules will lead, 
with more rapidity than in most instances of the excision 

1 Diet, des Sc. Med., Art. Humerus. 



DISSECTIONS. 43 

of joints, to a successful result, without exposing to the 
risk of the accident just mentioned. Anchylosis is said 
not to have occurred in a single instance after the numer- 
ous operations of the Schleswig-Holstein war. 1 



DISSECTIONS. 



In five dissections of the parts involved in this excision, 
three of which had been performed for caries, and two for 
accident, the patients having survived the operation 6 
months, 6, 10, 11, and 19 years, the functions of the arm 
being in all regained, anything resembling a capsular liga- 
ment was found only in one case ; the end of the humerus 
was sometimes rounded and sometimes surmounted by pro- 
cesses, into which the muscles were inserted in a confused 
mass. A deposit of fibro-cartilaginous or fibrous matter 
between the end of the humerus and the scapula united 
the former by ligamentous bands to the acromion and cora- 
coid processes and edges of the glenoid cavity, and by this 
the mobility of the limb was secured. 2 

In a remarkable case reported by Chaussier, where the 
head of the humerus, being carious, was eliminated by nat- 
ural processes, the opposing portion of the scapula formed 
a rounded head, which was received into a cavity hollowed 
out in the end of the humerus. 3 



1 Statham's Stromeyer and Esmarch, p. 65. 

2 Wagner, On the Process of Repair after Resection, etc., New Syd. Soc, 
Vol. V. p. 118. 

3 Magasin Encyclopedique, Vol. XXX. p. 521. 



44 EXCISION OF THE SHOULDER-JOINT. 



CONCLUSIONS. 

The conclusions which may be arrived at with regard 
to excision of the shoulder-joint are as follows : — 

First, That the earliest authenticated instance of the 
operation is a decapitation of the head of the humerus 
reported by Mr. James Bent, of Newcastle, England, and 
performed in October, 1771 ; the first complete excision 
having been by Moreau in July, 1786. 

Second, That when performed for traumatic cause it is 
fatal once in every 3§£ cases ; secondary excision being 
more successful than primary in the proportion of 17 to 
10. 

Third, That it is not a justifiable operation in cases of 
malignant disease of or about the shoulder-joint. 

Fourth, That excision or abstraction of the necrosed 
head of the humerus is almost uniformly successful. 

Fifth, That it is fatal once in every 6J, and fatal or un- 
successful once in every 4£ cases of its performance for 
white swelling. 

Sixth, That the ultimate results of all excisions of this 
joint, whether for injury or for disease, are very satisfac- 
tory, anchylosis being of exceptional occurrence. 

Seventh, That partial excision is not usually followed 
by the accidents which so often succeed it when done in 
the ginglymoid joints ; on the contrary, interference with 
the glenoid cavity seems materially to increase the dan- 
gers of the operation. 



EXCISION OF THE ELBOW-JOINT. 45 



ELBOW-JOINT. 



HISTORY. 

The case of Mr. Wainman, of Shripton, England, in 
which he sawed off the lower end of the humerus, just 
above the olecranon fossa, in a case of compound dislo- 
cation, is famous in the history of excisions for its very 
early date. The patient lived, and the limb was as flexi- 
ble " as if nothing had ever been amiss." The meagre 
details of this operation were first published in Henry 
Park's letter to Mr. Pott, dated September 18, 1782, and 
it is spoken of as having been performed " twenty-three 
years before " ; but whether before the date just named, 
or that of the excision of the knee (July 2, 1781), which 
is the subject of the letter, is not stated. Mr. Wainman 
must, therefore, have operated either in 1758 or 1759. 

The letter alluded to, and in which also Mr. Park for- 
mally proposed excision of the elbow, though he had not 
performed it himself, except upon the dead subject, elicit- 
ed the fact that Mr. Justamond, of London, in 1775, had 
excised the olecranon and two inches of the ulna for dis- 
ease, and that Mr. Tyre, of Gloucester, had cut off two 
and a half inches of the lower end of the humerus after a 
compound dislocation. 1 These partial excisions are the 
earliest ones which were practised upon the elbow-joint. 

The elder Moreau claims to have submitted to the 
French Academy in 1782 (the same year in which Park 
suggested it) a proposition to excise this joint. This was 
before he could have heard of Park's letter, which was not 
translated by Lassus until 1784. He did not operate, 
however, until 1794, when he performed the first com- 

1 Lond. Med. Journ., Vol. XL p. 282. 



46 EXCISION OF THE ELBOW-JOINT. 

plete excision of the elbow of which any mention is made. 
In June, 1797, the operation was performed by his son. 1 

Mazozza, of Milan, Sommeillier, Percy, and Champion, 
in France, are also mentioned as early operators, but the 
details of their cases are nowhere given. 2 Roux, who 
subsequently became one of its strongest advocates, oper- 
ated for the first time in 1819. 3 

In 1817 or 1818, the elbow was completely excised for 
the first time for disease in England by Mr. Josiah Stans- 
field, of Leeds, and in 1819 the operation was a recog- 
nized one in the Infirmary of that town, having been per- 
formed by two others of its surgeons, Messrs. Chorley and 
Hey. 4 In February, 1823, the elbow was excised in Dub- 
lin by Sir (then Mr.) Philip Crampton, 5 and in 1828, by 
Mr. James Syme in Edinburgh. The latter was so pleased 
with his success, that he declared that " carious joints might 
be cut into with the same impunity as ordinary abscesses, 
and cut out with no more danger than what attends am- 
putation, or rather not so much, since the balance of ac- 
tion will be less disturbed, cceteris paribus, when the limb 
is allowed to remain." 6 In 1831, this distinguished sur- 
geon published a memoir on the " excision of diseased 
joints," containing the records of 17 cases of elbow-excis- 
ion, 14 of which were his own. From this period on- 
wards, the annals of surgery furnish abundant examples, 
the gentleman just named having himself, in 1855, oper- 
ated "more than one hundred times." 7 

In the United States, the elbow was first excised by 
Dr. John C. Warren, of Boston, October 16, 1834. 8 The 
case was communicated verbally to Yelpeau, who alludes 

1 Jeffrey's Park and Moreau, pp. 82, 96, 110. 

2 Diet, des Sc. Med., Diet, en 30 Vol., Velpeau. 

3 Blackman's Velpeau, Vol. II p. 455. 

4 Lancet, Mar. 17, 1855. 

5 Dublin Hosp. Reports, Vol. IV. p. 191. 

6 Edinb. Med. and Surg. Journ., April, 1829. 

7 Lancet, Mar. 3, 1855. 

8 Mass. Gen. Hosp. Records. 



HISTORY. 47 

to it in his Medicine Operatoire, 1 but was never other- 
wise published. June 5, 1835, the operation was repeated 
by the late Dr. Thomas Harris, of the U. S. Navy; 2 af- 
terwards by Dr. Buck, of New York, in 1841, and by Dr. 
Pancoast, of Philadelphia, in 1842. 3 

Baron Larrey urged this excision upon his surgeons, 
but it does not appear that his advice was followed, for 
Percy says, that " timidity, carelessness, routine, and in- 
difference too often led them to prefer amputation, even 
under the very eyes of the old chieftain of military sur- 
gery." 4 Mr. Alcock, in his paper already referred to, 
writing in 1840, says : " Of the total excision of the ar- 
ticulating ends of the elbow-joint, I find no instance in 
the annals of either British or French military surgery." 5 
Wachter, 6 however, cites from Bilguer, who wrote in 1781, 
three cases in which fragments, comprising in one instance 
the whole elbow-joint, in another the ends of the humerus 
and ulna, and in the third those of the ulna and radius, 
were removed, and which at the end of several months 
recovered without anchylosis. It is mentioned also by 
both Jaeger and Tobold, that a German named Grocke, 
in 1793, performed a partial excision of the elbow for a 
gun-shot wound ; the patient, a soldier, recovering at the 
end of five months with an anchylosed joint. 7 

But it was not till the Schleswig-Holstein war of 1848 - 
1851, that this excision was really introduced and popular- 
ized in military practice, chiefly, as is generally admitted, 
through the exertions of B. Langenbeck of Berlin and L. 
Stromeyer of Erlangen, Surgeons-in-Chief of the above- 
named campaign. 8 

1 Blackman's Velpeau, Vol. II. p. 485. 

2 Am. Journ. of Med. Sc, Vol. XIX. p. 341. 

3 Philad. Med. Exam., Sept. 17, 1842. 

4 Diet, des Sc. Med., Vol. XL VII., Art. Resection. 

5 Med. Chir. Trans., Vol. XXIII. p. 254. 

6 De Artie. Extirp., p. 17. 

7 Op. Resect. Consp. chron. Adumb., p. 6. De Artie. Cubiti Resect., p. 8. 

8 Statham, Macleod, Petruschky, etc., etc. 



48 EXCISION OF THE ELBOW-JOINT. 

Excision of the elbow-joint has been performed for inju- 
ries, for disease, and for anchylosis, this being one of the 
two joints in the body to which, for the last-named cause, 
the operation has been considered applicable. 



EXCISION FOR INJURY. 



The elbow is the frequent seat of compound fracture and 
dislocation from various causes, and in battle its exposed 
position in both loading and firing makes it constantly lia- 
ble to gun-shot injuries. 

For such accidents, met with in civil practice, as from 
their extent or severity require excision of the elbow, the 
operation has been performed with much success, the posi- 
tion of the patient afterwards, and the general character of 
the injuries, as compared with those occurring in military 
practice, simplifying considerably the choice between it and 
amputation. 

In a paper by Mr. Jonathan Hutchinson, 1 the conclu- 
sions drawn from a series of 12 cases of severe injury of 
the elbow-joint, variously treated, are, that primary amputa- 
tion ought never to be thought of, unless either the artery 
be torn through, or the soft parts in front as well as be- 
hind ; that it is far better surgery to excise the ends of the 
bones, than to be content with simple reduction ; that cases 
with the smallest opening in the integuments are generally 
the most serious ; that less suppuration and less constitu- 
tional disturbance appear to follow, and the chances of 
good motion are infinitely greater after excision, than when 
the injured ends of the bones are allowed to remain. 

The success which attends the operation in civil hospi- 
tals and private practice is quite remarkable. Of 21 cases, 

1 Med. Times and Gazette, July 12, 1856. 



EXCISION FOR INJURY. 49 

the facts of which are in my possession, but a single one re- 
sulted fatally, and then from causes in no way attributable 
to the excision. In all the others a rapid recovery ensued, 
leaving a limb of variable serviceableness, but vastly better 
than none, or than any artificial substitute. A greater 
number of facts, it is believed, would only confirm these 
results. As compared with amputation, the contrast as to 
mortality is strikingly in favor of excision, since of 13 am- 
putations of the upper extremity for traumatic cause, per- 
formed in Guy's Hospital, 23 per cent, or 1 in 4.33 of 
primary, and 20 per cent, or 1 in 5 of secondary opera- 
tions, proved fatal. 1 

It may be a question whether the operation is as properly 
applicable to compound dislocations, uncomplicated with 
fracture, as to compound and comminuted fractures. This 
point is not brought out by the cases above referred to, and 
I am not in possession of facts to illustrate it. The opin- 
ions of Dr. Hamilton (p. 5) and of Mr. Hutchinson are, 
however, strongly in favor of it, and the error, it seems to 
me, is liable to be rather on the side of reduction than on 
that of the operation. 

The greater extent to which gun-shot wounds are apt, 
as a rule, to involve the soft parts with the large vessels 
and nerves, or to splinter the bones, to say nothing of the 
unpropitious conditions for subsequent care in which the 
patient is placed by the exigencies of a campaign, must 
often render the choice of operation difficult and embar- 
rassing ; far more so than in injuries of the shoulder, a 
joint which can, by its anatomical position, even under ad- 
verse circumstances, be kept tolerably immovable, and, con- 
sequently, free from many sources of after trouble, with 
much greater ease than the elbow. Either for this reason, 
or some other, injuries of the joint of the elbow less fre- 
quently do well after gun-shot wounds than those of the 



1 Med. Chir. Trans., Vol. XLII. p. 71. 
5 



50 EXCISION OF THE ELBOW-JOINT. 

shoulder. Larrey noticed how often tetanus followed them, 
and every surgeon is aware of their gravity. 

The diagnosis of gun-shot wounds of this joint, with ref- 
erence to the extent of the injury, is not always easy ; and 
it has been observed that in fractures (gun-shot) of the 
humerus just above the joint, fissures extend downward 
oftener than upward ; and the apparently trivial accident 
of a fissure into a joint, although not necessarily followed 
by serious results, is nevertheless frequently succeeded by 
the most disastrous consequences. 1 

When left to nature, the track of a ball which passes 
near the joint, as well as the joint itself, usually becomes 
carious, and ultimately requires excision. " I have seen," 
says Macleod, " several cases in which, after being trav- 
ersed by a ball, attempts have been made to save the elbow 
without excising it, but such trials were anything but en- 
couraging. The motion of the joint and its consequent use 
will be found much greater after excision than when the 
arm has been saved without such an operation." 2 

The approval of and growing confidence in this opera- 
tion is shown by the fact, that in the Schleswig-Holstein 
campaign, for simple shattering of the elbow-joint by bul- 
lets, without other complication, six amputations were per- 
formed in 1848, three in 1849, and none in 1850, excis- 
ions having taken their place. Of 40 instances of the 
latter, during the years just named, 6 only were fatal. 
In one case, amputation, on account of gangrene, was sub- 
sequently performed, and one was still under treatment. 
The remaining 32 resulted in a more or less useful arm. 
In 8, the general flexibility and mobility at the elbow were 
very extensive ; in 9, tolerably so. In 13, more or less 
complete anchylosis took place, and of 2 the ultimate 
issue was not known. The frequency with which anchy- 
losis occurred was attributed to the fact that a large num- 
ber of the patients were treated after the excision by Dan- 

1 Macleod, Surgery of the Crimean War, p. 308. 

2 Ibid., p. 327. 



EXCISION FOR INJURY. 51 

ish surgeons, who, having never practised the operation, 
were ignorant of the importance of timely passive motion, 
and entirely neglected it. 

In amputations of the arm, performed during the above 
campaign, 19 out of 54 were fatal. 1 

In the Crimean war, 22 excisions of the elbow were 
performed, of which 3 ended fatally ; 2 deaths also oc- 
curred after secondary amputation. 2 Of 153 arm ampu- 
tations, 29 were fatal. 3 Of 33 primary disarticulations of 
the elbow 28 were fatal, and 24 of 31 secondary disar- 
ticulations. 4 

Grouping these cases, we have, excluding the one un- 
der treatment and that in which subsequent amputation 
was performed, 60 excisions with 11 unfavorable results, 
or a mortality of 18.33 per cent, and, adding the one ex- 
cluded above, 208 amputations with 48 deaths, or a mor- 
tality of 23.07 per cent. This gives a percentage of 4.74 
in favor of excision. The mortality of disarticulation, it 
will be observed, has a much greater rate than either. 

In cases not thought to require excision at the outset, 
secondary excision at the end of a week ought not, it 
would seem, to modify the result. If the objection to 
meddling with inflamed joints is without any definite rea- 
son, the relief which, it is said, 5 follows incisions into them 
under such circumstances, would probably be increased by 
the removal of the injured bone and cartilage. Such is 
the opinion of Stromeyer, who observes that, " as regards 
the results, it is of no consequence whether the resection is 
performed in the first forty-eight hours, or after the full de- 
velopment of suppuration." 6 This is further shown by the 
statistics of Esmarch, according to which, of 11 excisions 



1 Statham, op. cit, pp. 79, 86, 87. 

2 Dublin Quarterly, Aug. 1859, p. 85. 

3 Med. Times and Gazette, Sept. 13 and 20, 1856. 

4 Ibid., June 9, 1860. 

5 Lancet, Nov. 22, 1851. 

6 Statham, op. cit., p. 25. 



52 EXCISION OF THE ELBOW-JOINT. 

within the first twenty-four hours of the injury, one died ; 
of 20 performed during the inflammatory stage, that is, 
from the second to the fourth day, 4 died. Of 9 second- 
ary excisions performed from the eighth to the thirty- 
seventh day, only one died. 1 

The Crimean war taught that " partial excisions, of 
which there were a good many cases, did not turn out, 
on the whole, at all so well as complete ones. They were 
more tedious, more liable to fail, and less satisfactory when 
they succeeded, than when the whole articulation was re- 
moved." 2 Esmarch disapproves of partial excision, and 
thinks "that the extensive severing of the ligamentous 
apparatus of the joint is what deprives the wound of its 
danger ; the less there is removed from the joint-ends of 
the bones, the greater is the probability of anchylosis." 3 
On the other hand, Stromeyer rather advocates the prac- 
tice, " because experience teaches that anchylosis of the 
arm in an obtuse angle does not interfere much with its 
use." 4 

In but 7 of the 21 cases of excision for injury, to which 
reference has been made, occurring in civil practice, was 
partial excision performed ; three were followed by good 
results ; one resulted in partial anchylosis ; in one the 
elbow could not be perfectly extended ; in one the unsat- 
isfactory result was attributed to habits of intemperance ; 
and of one we have no special account. 

Even if a satisfactory conclusion cannot be arrived at 
from these data, there is no reason to suppose that this 
articulation offers any exception to the general rule with 
respect to the point at issue. 

A single remark may be made with regard to treat- 
ment, and that is, that poultices are decidedly prejudicial 
applications in the class of cases which have just been dis- 
cussed, adhesive processes being prevented by their use, 
and suppuration and ulceration being excited. Such is 

1 Statham, op. cit., p. 87. 3 Stathara, op.cit., p. 79. 

2 Macleod, op. cit., p. 336. 4 Ibid., p. 25. 



EXCISION FOR ANCHYLOSIS. 53 

the opinion of Guthrie, 1 Sir Astley Cooper, 2 and of Mr. 
Hutchinson, in his paper already alluded to. My own 
observation is confirmatory of this conclusion. Their 
omission is, however, a matter of difficulty, so agreeable 
are they to the patient; their long employment should 
at least be prevented, and their use discontinued as soon 
as possible. 



EXCISION FOR ANCHYLOSIS. 

Dr. John Eea Barton, of Philadelphia, in 1827, rec- 
ommended removal of the ends of the bones of the elbow- 
joint as a means of curing anchylosis, 3 though an opera- 
tion done by Textor in 1823 4 may perhaps have antici- 
pated his suggestions. Of late years many surgeons have 
put in practice this method of treatment. 

Mr. Fergusson operated on a man thirty-four years old, 
for anchylosis of the elbow from unreduced dislocation of 
seven years' standing, and at the end of three months there 
was a limited amount of motion. 5 In another case, where 
a man aged thirty had dislocated the ulna backward and 
the radius forward, and anchylosis had followed, excision 
was performed ten months afterwards, viz. June 7, 1856. 
Passive motion was commenced June 18th. September 
25th there was some pronation and supination, and the 
hand could be brought up to the whiskers. In Novem- 
ber the patient was discharged, with a good degree of 
motion. 6 

Mr. Holthouse operated on the right elbow of a female 
aged twenty-one, both of whose arms were anchylosed from 

1 On Gun-shot Wounds, p. 66. 

2 On Dislocations and Fractures, p. 414. 

3 North Am. Med. and Surg. Journ., April, 1827. 

4 A. M. Thore, De la Resection dela Coude, (Paris, 1843,) p. 36. 

5 Med. Times and Gaz., Jan. 15, 1853. 

6 Lancet, Oct. 4, 1856. 

5* 



54 EXCISION OF THE ELBOW-JOINT. 

rheumatism, removing a flat plate of bone. Nearly the 
natural range of movement was regained, and with little 
prospect of subsequent impairment. 1 

Mr. Syme operated on a young man, both of whose arms 
were permanently extended, one from dislocation, the oth- 
er from fracture and dislocation. One elbow was immov- 
able, the other had slight motion. Excision gave a result 
" so perfect, that the arm could not be distinguished from 
a sound one till the sleeve was removed." 2 

Two cases in which the arms were fixed in a straight 
position are referred to by Mr. Bickersteth, of Liverpool. 
Unable even to feed themselves, these unfortunate indi- 
viduals were entirely dependent on the assistance of oth- 
ers. In each case the right elbow was excised, and the 
limb rendered useful and movable. 3 

A partial excision of the elbow for anchylosis, resulting 
only in an improved position, is reported by Dr. G. Buck 
of New York. 4 

Other cases in large numbers might be cited, but these 
are sufficient to give an idea of the circumstances thought 
to require, and the results likely to follow, the operation. 

The condition of the parts in the neighborhood of unre- 
duced dislocations and badly treated or united fractures, 
the enlargement of the bones and their interlocking, often 
render excision of their ends an operation of difficulty. 
Such was the case in the first of Mr. Fergusson's opera- 
tions alluded to. And if the bones are not excised so 
freely as to leave a considerable interval between them, 
the tendency to reunion will be so great as to be with diffi- 
culty overcome. 

Although success is frequent, still, considering its un- 
certainties, the operation, it seems to me, can hardly be 
undertaken with propriety, except in cases where the arm 



1 Lancet, Oct. 4, 1856. 

2 Ibid., Mar. 3, 1855. 

8 Liverpool Med. Chir. Journ., July, 1857, p. 201. 
4 Am. Journ. of Med. Sc, April, 1843, p 297. 



EXCISION FOR DISEASE. 55 

has stiffened either in a straight position, or in one of 
extreme flexion ; or unless some special circumstances in 
an individual's position authorize an experiment, the re- 
sults of which may be only a renewed anchylosis. 



EXCISION FOR DISEASE. 

Thirty years ago, in all incurable diseases of the elbow, 
the necessity of amputation was considered inevitable. 
Now, no excision has been so frequently performed as that 
of this joint, or with such generally successful results, and 
no capital operation has a more fixed and recognized posi- 
tion in surgery. At Guy's Hospital, for instance, amputa- 
tion for disease of the elbow is so rare, that in five years but 
a single instance of it had occurred, though in the same 
period eight excisions were performed, with one death and 
one subsequent amputation ; in the remainder, a good arm 
being preserved. 1 

But little need be added to what has already 'been said 
as to the conditions requiring excision. Although Lebert 
says it has been successfully applied for malignant disease, 2 
I have met with no published instance of its performance. 
Ulceration of the cartilages and caries of the ends of the 
bones — " white-swelling " in its varying forms — is almost 
the only affection for which excision of the elbow is ever 
contemplated. Its frequency in this joint, in the hospital 
just now mentioned, is as one to four of the hip and knee, 
which are the most often diseased. 3 

In cases suggesting excision, the existence of a certain 
amount of constitutional vigor and the failure of patient 
waiting for a cure by Nature must be ascertained facts, as 

i Bryant, Dis. and Inj. of Joints, (Lond. 1859,) p. 136. 

2 Maladies Cancereuses, (Paris, 1851,) p. 731. 

3 Bryant, loc. cit. 



56 EXCISION OF THE ELBOW-JOINT. 

well as that the disease has reached an incurable state, 
either from utter want of all rational remedial means, or 
through their inability to arrest its progress. That such a 
point has been attained, the eye and the hand of the sur- 
geon can decide better than words describe. There is one 
feature, however, to which Mr. Fergusson calls such special 
attention that I cannot pass it by. This is, to quote his 
own words, " an elasticity about the joint which can be 
appreciated by pressing the ulna against the end of the 
humerus, as also by swinging the fore-arm laterally. If 
there is much mobility and elasticity under such move- 
ments, I consider the joint as most seriously involved, and 
that in all probability the best treatment will be excision, 
for, when the above condition is present, I believe all hope 
of cure for years to come may be set aside." 1 

Within certain limits the extent of the disease is not a 
hindrance to the performance of the operation. That the 
roughened and stalactitic state to which the shafts of the 
bones in the vicinity of a diseased elbow are particularly 
prone, resulting from contiguity to the centre of morbid 
action, is not an objection to excision, is most satisfactorily 
answered by the success with which it is performed. It is 
a condition very different from caries itself, and the result 
of a process tending to limit rather than increase the dis- 
ease. Although sometimes requiring removal, the out- 
growth usually disappears when the source of irritation is 
taken away, just as the thickened and indurated tissues 
surrounding the joint soften down and are replaced under 
a healthier action. 

The condition of the soft parts is in fact a more impor- 
tant point than that just considered ; for if it is such that 
they can only slowly assume a healthy state, it may lead to a 
return of the disease of the bones. Two cases, where the 
disease of the integument persisted after the operation and 
the caries reappeared, are mentioned by Dupuytren as ter- 
minating finally in amputation, and a similar instance is 

1 Syst. of Pract. Surg., (4th ed., Lond.,) p. 297. 



EXCISION FOR DISEASE. 57 

cited by M. Thore ; within a month of the excision the soft 
parts had relapsed into a most unhealthy state, and seven 
or eight months afterward the patient died. Upon one 
occasion M. Roux thought it necessary to cut the soft parts 
away largely, on account of their diseased condition, and 
trust to the slow processes of granulation for their restora- 
tion. 

The histories of collected cases show that the sources of 
failure lie chiefly in the patient's general condition and 
tendencies ; that the cases demanding subsequent amputa- 
tion are few in proportion to the whole number of opera- 
tions, and that death rarely occurs from causes connected 
with the excision itself. 

In 1831 Mr. Syme said : " I have cut *out 14 elbow- 
joints, and the operation has been performed in Edinburgh 
three times by other practitioners ; of all these 17 cases, 
only two have terminated fatally, and in one of them the 
patient would, I believe, have died from any operation 
whatever ; while in the other, the disease was found so 
extensive as to render the excision almost impracticable. 
I believe that the result of 17 amputations in similarly un- 
favorable constitutions would not be so satisfactory." x 

Mr. Bickersteth, of Liverpool, operated on 19 patients, 
and only 2 died from the operation ; one, of delirium tre- 
mens on the twenty-sixth day, the case proving fatal in thir- 
ty-six hours ; the other, a feeble woman, sixty-four years of 
age, who died between the second and third week. 2 In 14 
excisions of the elbow, Mr. Erichsen had but one death; 3 
and of 11 patients operated on by Roux, all of which were 
complete excisions, 3 died. 4 This, it should also be remem- 
bered, was in Parisian hospitals, notorious for the bad re- 
sults of capital operations. 

The following table will, however, exhibit more exactly 
the results of excision of the elbow-joint. 

1 On the Excision of Diseased Joints, (Edinb.,) p. 26. 

2 Liverpool Med. Chir. Journ., July, 1857, p. 201. 

3 Science and Art of Surgery, (3d ed., London,) p. 706. 

4 Brit, and For. Med. Chir. Rev., July, 1841, p. 253. 



58 



EXCISION OF THE ELBOW- JOINT. 



No. 
1 


Authority. 


Sex. 


Age. 


Partial or 
Complete. 


Time under 
Treatment. 


Lancet, Jan. 18, 1853. 


F. 


44 


Complete. 


8 mos. 


2 


Ibid., Dec. 4, 1852, 


M. 


24 


Partial. 


8 mos. 


3 


Ibid., Dec. 11, 1852. 


M. 


35 


Complete. 


16 days. 


4 


Med. Times and Gaz., June 23, 1855. 


F. 


38 


Partial. 


3 weeks. 


5 


Ibid., Jan. 3, 1857. 


M. 


8 


«« 




6 


Ibid., Feb. 20, 1858. 


M. 


10 


Complete. 


6 mos. 


7 


Dublin Hosp. Rep., Vol. IV. p. 191. 


M. 


23 


Partial. 


7 mos. 


8 


Lancet, Oct. 4, 1856. 


M. 


4i 


«( 


3 mos. 


9 


Ibid., Oct. 11, 1856. 


F. 


20 


" 


11 mos. 


10 


Ibid. 


F. 


31 


Complete. 


3 mos. 


11 


Ibid. 


F. 


57 


tt 


2 mos. 


12 


Ibid. 


M. 


17 


" 


2 mos. 


13 


Ibid., Mar. 3, 1855. 


M. 


38 


tt 




14 


Med. Times and Gaz., Mar. 31, 1855. 


M. 


21 




1 month. 


15 


Ibid., May 12, 1855. 


M. 


20 


Complete. 


3 mos. 


16 


Lancet, Jan. 28, 1854. 


M. 


45 


u 


1 year. 


17 


Thore (These), p. 81. 


F. 


26 


u 


18 mos. 


18 


Med. Times and Gaz., Apr. 21, 1860. 


M. 


45 


a 


1 year. 


19 


Ibid. 


M. 


25 


tt 


9 mos. 


20 


Ibid. 


M. 


16 


tt 


2 mos. 


21 


Ibid. 


M. 


13 


Partial. 


9 mos. 


22 


Ibid., May 5th, 1860. 


M. 


29 


Complete. 


6 weeks. 


23 


Lancet, Nov. 28, 1857. 


F. 


21 


tt 


6 mos. 


24 


Ibid. 


F. 


14 


tt 


3 mos. 


25 


Ibid. 


M. 


26 


a 


2 mos. 


26 


Philad. Med. Ex., Sept. 24, 1852. 


M. 


32 


a 


3 mos. 


27 


Thore (These), p. 24. 


M. 


50 


tt 


Ah mos. 


28 


Ibid., p. 26. 


M. 


26 


" 


4f mos. 


29 


Ibid., p. 52. 


M. 


27 


tt 


16 days. 


30 


Ibid , p. 58. 


M. 


10 


Partial. 


7 days. 


31 


Ibid., p. 71. 


F. 


41 


Complete. 


5 mos. 


32 


Ibid., p. 74. 


M. 


22 


a 


11 mos. 


33 


Lancet, Oct. 1, 1857. 


F. 


3jLm. 


tt 


3^ mos. 


34 


Chicago Med. Journ., Sept. 1858. 


M. 


26 


" 


14 mos. 


35 


Am.Journ.ofMed.Sc.,Vol. XIX. 1836. 


F. 


26 


" 


6 mos. 


36 


Ibid., Oct. 1856. 


F. 


28 


" 


6 mos. 


37 


New York Med. Journ., Mar. 1860. 


F. 


30 


tt 




38 


Lancet, Nov. 28, 1857. 


M. 


13 


tt 




39 


Med. Times and Gaz., May 8, 1858. 


M. 


16 


tt 


6 weeks. 


40 


Ibid. 


F. 


16 


" 


1 month. 


41 


Ibid. 


F. 


20 


« 


1 month. 


42 


Guy's Hosp. Reports, 1836, p. 268. 


M. 


30 


tt 


11 mos. 


43 


Ibid., 1840, p. 81. 


M. 


26 


tt 




44 


Ibid. 


M. 


43 


Partial. 


6 weeks. 


45 


Ibid., 1841, p. 369. 


M. 


17 




2 mos. 


46 


Mass. Gen. Hosp. Records. 


M. 


52 


Partial. 


4 weeks. 


47 


Ibid. 


M. 


35 


a 


5 mos. 


48 


Ibid. 


M. 


24 


Complete. 


5 mos. 


49 


Ibid. 


M. 


29 


a 


6 mos. 


50 


Med. Times and Gaz., May 3, 1856. 


F. 


15 


" 


6 mos. 


51 


Ibid. 


F. 


20 


" 


6 mos. 


52 


Ibid. 


F. 


20 


it 


4 mos. 


53 


Ibid., Aug. 9, 1856. 




5 


Partial. 


2 mos. 


54 


Ibid., June 12, 1858. 


M. 


24 


Complete. 


9 mos. 


55 


Ibid., Dec. 13, 1856. 


F. 


11 


it 


2 mos. 


56 


Ibid. 


M. 


63 


ft 


2 mos. 


57 


Lancet, Mar. 22, 1 856. 


M. 


11 


Partial. 


8 mos. 


58 


Ibid., Oct. 4, 1856. 


F. 


23 


Complete. 


6 weeks. 


59 


Ibid. 


F. 


10 


«< 


3 mos. 


60 


Ibid., Oct. 11, 1856. 


F. 


25 


tt 


4 mos. 



EXCISION FOR DISEASE. 



59 



Termination. 



Remarks. 



Useful arm. 
Not healed. 
Died. 

Anchylosis. 
Useful arm. 

U K 

Amputated. 
Anchylosis. 



Useful arm. 
Died. 
Useful arm. 



Died. 

Useful arm. 
Anchylosis. 
Amputated. 
Useful arm. 



Died. 

u 

Useful arm. 



Amputated. 
Useful arm. 



Died. 

Useful arm. 
Amputated. 
Useful arm. 



Amputated. 
Useful arm. 



Died. 
Unpromising, 



Operator condemned for not amputating. 

Not in an encouraging state. 

Erysipelas. Left arm. 

Pneumonic phthisis. 

Excision of outer condyle. 

Amputation thought by many the proper operation. 

Slight degree of motion. Able to write. Right arm. 

Disease returned. Left arm. Recovered. 

Head of radius, which was left, found carious. R. arm. Recov, 

Right arm. 

Elbow not of much use. 

Wrist and fingers useful. Right arm. 

Knows no difference in his two arms. 

Pyaemia. 

Good motion. 

Returned to his employment. 

Movements remarkably free. 

Right arm. 

Phthisis. Parts not in a hopeful condition. Left arm. 

Fair amount of motion. Right arm. 

Good use of hand and fore-arm. 

Profuse suppuration. Recovered. 

Almost perfect flexion, extension, and rotation. Right arm. 

Plenty of motion. Left arm. 

Can raise his hand to his mouth. Right arm. 

Free flexion and extension. Right arm. 

Uses his arm as well as any one. Right arm. 

Tolerably free motion. Left arm. 

Erysipelas. Right arm. 

Convulsions. Left arm. 

Movements tolerably free. Left arm. 

Flexion and extension free. Right arm. 

Flexion enough to let thumb reach mouth. Left arm. 

Dresses and feeds himself. Flexion 50°. Earns fine wages. 

Nearly all the motions of the joint. 

Extension, flexion, supination, pronation. 

Perfect use of arm. Right arm. 

Good use of arm. Left arm. 

Flexion and extension free. 

Recovered. Extension of disease. 

Recovery rapid and complete. 

Remarkable freedom of motion. Right arm. 

Resumed occupation of postman. Right arm. 

Can raise a heavy stool above his head. Left arm. 

Able to carry hand to mouth. Left arm. 

Exhaustion. 

Phthisis. Right arm. 

Motions limited. Right arm. 

Disease of bones returned. Recovered. Right arm. 

Good recovery. 

Movements of joint almost perfect. 

Can write and sew. 

Disease of soft parts. Recovered. 

Lifts a heavy chain ; carries a bucket. Left arm. 

Fair motion. 

Fair motion. 

Limited flexion. Right arm. 

Promises improvement. 

Phthisis. 

Right arm. 



60 



EXCISION OF THE ELBOW-JOINT. 



No. 


Authority. 


Sex. 


Age. 


Partial or 
Complete. 


Time under 
Treatment. 


61 


Med. Times and Gaz., Oct. 13, 1855. 


M. 


14 


Complete. 


3 mos. 


62 


Lancet, Jan. 28, 1854. 


M. 


37 




9 mos. 


63 


Ibid. 


M. 


60 


Complete. 


2 weeks. 


64 


Ibid., Dec. 11,1852. 


F. 


5 


Partial. 


2 weeks. 


65 


Ibid. 


M. 


12 


" 


7 weeks. 


66 


Ibid. 


F. 


8 


Complete. 


4 mos. 


67 


Ibid., Jan. 15, 1859. 


M. 


40 


« 




68 


Ibid., May 31, 1851. 


M. 


31 


it 


4 mos. 


69 


Med. Times and Gaz., Nov. 4, 1854. 


F. 


50 




2 years. 


70 


Ibid., June 5, 1858. 


F. 


14 




3 mos. 


71 


Ibid. 


F. 


15 




3 mos. 


72 


Lancet, April 27, 1850. 


M. 


17 


Complete. 


8 mos. 


73 


Dublin Quarterly, Feb. 1859. 


F. 


25 


<( 


9 mos. 


74 


Ibid. 


M. 


24 


Partial. 


9 mos. 


75 


Edinb. M. and S. Journ., Aug. 1859. 


M. 


13 


Complete. 


13 mos. 


76 


London Med. Gaz., Vol. X. p. 430. 


M. 


18 


u 


1 month. 


77 


Ibid., Vol. VII. p. 555. 


F. 


24 


i< 


5 mos. 


78 


Med. Times and Gaz., Apr. 30, 1859. 


F. 


10 


n 


4 mos. 


79 


Ibid., Apr. 21 and May 5, 1860. 


M. 


32 


it 




80 


Dublin Quarterly, Nov. 1855. 


M. 


56 


a 


6 weeks. 


81 


Lancet, Mar. 19, 1859. 


M. 


16 


a 


9 mos. 


82 


Med. Times and Gaz., Apr. 30, 1859. 


M. 


18 




10 weeks. 


83 


Am. Journ. of Med. Sc, Oct. 1846. 


M. 


25 


Complete. 


6 mos. 


84 


Lancet, Aug. 26, 1848. 


M. 


16 


it 


3 mos. 


85 


Association Journal, Aug. 4, 1854. 


M. 


21 




Several mos. 


86 


Ibid. 


F. 


21 




Many mos. 


87 


Ibid., June 23, 1854. 


M. 


49 




3 mos. 


88 


Ibid. 


M. 


22 




1 year. 


89 


Med. Times and Gaz., Apr. 30, 1859. 


F. 


21 






90 


Ibid., Aug. 19, 1854. 


M. 






1 month. 


91 


Ibid., May 1, 1852. 


M. 


30 


Complete. 


6 mos. 


92 


Ibid., Jan. 3, 1852. 


M. 


16 


tt 


7 mos. 


93 


Ibid. 


M. 


12 


" 


1 year. 


94 


Lancet, Jan. 15, 1859. 


M. 


38 


it 




95 


A.Tobold, De Artic.Cub. Resect.,p.l 7. 


M. 


16 


a 


7 mos. 


96 


Jeffray's Park and Moreau, p. 96. 


M. 


19 


a 




97 


Ibid., p. 110. 


M. 




tt 


7 mos. 


98 


Ibid., p. 114. 


M. 




Partial. 


3 mos. 


99 


Schillbach, Resect, der Knoch., p. 177. 


M. 


25 


Complete. 


7 mos. 


100 


Ibid., p. 183. 


M. 


30 


" 


9 mos. 


101 


Ibid., p. 187. 


M. 


26 


a 


3 mos. 


102 


Ibid., p. 195. 


M. 


59 


a 


1 month. 


103 


Ibid., p. 202. 


M. 


27 


Partial. 


5 mos. 


104 


Heyfelder, Resect, und Amp., p. 136. 


M. 


23 


tt 


16 weeks. 


105 


Ibid., p. 139. 


M. 


34 


tt 


10 weeks. 


106 


Ibid., p. 140. 


F. 


61 


Complete. 


6 days. 


107 


Ibid., p. 142. 


M. 


43 


tt 


2 mos. 


108 


Ibid., p. 145. 


F. 


33 


a 


9 mos. 


109 


Med. Times and Gaz., Aug. 4, 1860. 


F. 


21 


« 


1 month. 


110 


Tr. Path. Soc. Lond., Vol. IX. p. 223. 


F. 


47 


it 


5 days. 


111 


Med. Times and Gaz., Sept. 8, 1860. 


M. 


68 


tt 


4 mos. 


112 


Am. Med. Times, Sept. 22, 1860. 


M. 


23 


it 


10 mos. 


113 


Ibid. 


M. 


18 




2^ mos. 


114 


Ibid. 


M. 


10 


Complete. 


2 mos. 


115 


Ibid. 


M. 


14 




7 weeks. 


116 


Ibid. 


M. 


40 




2 weeks. 


117 


Statham's Resections, p. 117. 


F. 


74 


Complete. 


8 mos. 


118 


Lancet, Nov. 3, 1860. 


M. 


30 


Partial. 


10 mos. 


119 


Arch. Gen. de Med., [4.] T. 24, p. 357. 


F. 




Complete. 














EXCISION FOR DISEASE. 



61 



Termination. 



Useful arm. 
(« << 

Amputated. 
Died. 
Useful arm. 



Died. 

Useful arm. 
Anchylosis. 
Useful arm. 



Amputated. 
Useful arm. 
Amputated. 
Useful arm. 

Amputated. 

Useful arm. 

u (« 

Amputated. 



Useful arm. 

It It 

Died. 

Useful arm. 
Anchylosis. 

Useful arm. 



Died. 
Useful arm. 



Died. 

Useful arm. 
Amputated. 
Useful arm. 
Died. 
Useful arm. 



Amputated. 
Useful arm. 
Anchylosis. 
Useful arm. 



Remarks. 



Promises improvement. 

Works at shoemaking. Left arm. 

Died of phthisis six weeks after amputation. 

Pyaemia. Right arm. 

Serves all ordinary purposes. Right arm. 

Movements free. 

Equal to its fellow. Right arm. 

Movements free and strong. Right arm. 

Does duty of a cook in a large house. 

Fair motion ; improving daily. 

Hectic and exhaustion. 

Flexion free ; lifts a fifty-six pound weight. Left arm. 

Five inches removed. Uses hand perfectly. Right arm. 

Is now a day-laborer. Right arm. 

Nearly as efficient as the other. 

Motions sufficiently free. Right arm. 

Neuralgia. Recovered. Left arm. 

Fair motion. 

Recovered. Right arm. 

Good motion. Right arm. 

Almost as good as the other. Right arm. 

Disease of soft parts. Recovered. 

Motions free and strong. Right arm. 

Motions limited. Right arm. 

At patient's request. Returning disease. 

Limb being an encumbrance. 

For pain. Died ten months after. 

Good flexion. 

Fair motion. 

Pneumonia. 

Works like other people. Left arm. 

Useful hand. Nearly whole ulna removed. Right arm. 

Useful hand. Right arm. 

Equal for all purposes to its fellow. Right arm. 

Motion free and strong. Left arm. 

Motions extensive. Left arm. 

Flexion good. Right arm. 

Works as a shoemaker. Right arm. 

As powerful and useful as the other. Left arm. 

Resumed trade of carpenter. Right arm. 

Complete use of elbow. Right arm. 

Pyaemia. Left arm. 

Motions very limited. Right arm. 

Does duties of a servant. Right arm. 

Motions only tolerable. Left arm. 

Death from exhaustion. Right arm. 

Works on a railroad. Right arm. 

Useless limb at end of three years. Right arm. 

Does household duties with ease. Left arm. 

Death from exhaustion. Right arm. 

Excellent motion. Left arm. 

Excellent motion. Left arm. 

Considerable motion. Left arm. 

Good strength and motion. Right arm. 

" Very free motion." 

On account of disease of soft parts. Recovery. 

Motion at elbow ; stiff fingers. Left arm. 

" Indifferent result." Right arm. 

Flexion, extension, supination perfect. 

6 






62 EXCISION OF THE ELBOW-JOINT. 

The foregoing table is made up from a great variety 
of sources, as the references prove. It comprises all the 
cases which, with histories attached, have fallen within my 
range of research (excluding Mr. Symes's series), and the 
disease in every instance was " white swelling " in some 
one of its various phases and stages. 

Of the 119 cases of which it consists, 80 were males 
and 38 females, the sex in one case not being mentioned. 
In only 73 is the side operated upon reported, and of 
these 48 were of the right and 25 of the left. The age 
of the oldest patient, of those where it is stated, was 74 
years, and of the youngest, 14 weeks ; both of these re- 
covered, the former with a flexible elbow but stiff fingers, 
the latter with a useful arm. 

A fatal termination occurred in 15 cases, from the fol- 
lowing causes, and at the subjoined periods of time after 
the operation : — 

3 of phthisis, at the end of 9, 5, and 3 months respec- 
tively. 

1 of phthisis and pneumonia, at the end of 6 weeks. 

1 of pneumonia, at the end of one month. 

4 of exhaustion, at the end of 3 months, 4 weeks, 6 
and 5 days. 

3 of pyaemia, at the end of one month in two, and 2 
weeks in the third. 

2 of erysipelas, at the end of 16 weeks in each case. 
1 of convulsions, at the end of 7 days. 

In 15 cases, subsequent amputation was rendered ne- 
cessary for the following reasons, and after the periods of 
time named in connection with each : — 

In 2 the limb being an encumbrance; one at the end 
of 3 years, the other after " many months." 

In 3 for disease of the soft parts, at the end of 10, 8, 
and 2 weeks. 

In 5 for returning disease of the bones, at the end of 
11, 6, 5, 3, and 1 months. 

In 2 for pain, at the end of 5 and 3 months. 



EXCISION FOR DISEASE. 63 

Iii 1 for profuse suppuration, at the end of 6 weeks. 

In 2 for reasons not given, at the end of 2 weeks, and 
of a period not stated. 

From these amputations, 10 patients recovered and 2 
died ; one at the end of 10 months, for a cause not men- 
tioned, the other of phthisis at the end of 6 weeks. In 3 
the result of the secondary operation is not stated. 

Of the 89 cases recovering without amputation, 77 re- 
gained useful arms. In 8 the operation was followed by 
anchylosis, the hand and fore-arm remaining useful. One 
case at the end of 8 months was unhealed and in a dis- 
couraging state ; one at the expiration of 4 months was 
" unpromising," and one, with a movable elbow, had yet 
a stiff wrist ; while in still another the result was an " in- 
different one." 

The degree of usefulness retained varies from a condi- 
tion where only the hand was serviceable, up to a perfec- 
tion nearly equal to that of the natural state. Too great 
mobility sometimes impairs the serviceableness of an arm 
as much as too great rigidity. Such a result appears to 
have occurred not unfrequently in the experience of M. 
Roux. (Thore.) Flexion is generally better performed 
than extension, whilst pronation and supination often re- 
main quite perfect. A frequent test of strength appears 
to have been the carrying of a pail of water, and this 
seems often enough to be readily done. One of Moreau's 
patients ultimately threshed corn and held the plough. 
A patient of Mr. Key's became a letter-sorter in the post- 
office. A railway guard, operated on by Mr. Syme, says 
he knows no difference in his two arms. A patient of Mr. 
Cock's, nine months after the operation, boasted that he 
could make more shoes in a given time than any man in 
London. In fact, in all successful cases, the ordinary 
occupations of life are resumed, and patients soon learn 
to accommodate themselves to the limitation of move- 
ments which follows the operation. 

The perfect co-ordination of muscular action which char- 



64 EXCISION OF THE ELBOW-JOINT. 

acterizes the normal state of things is almost always some- 
what deranged. Flexion, for example, is accomplished 
in two steps; first the triceps contracts, the fore-arm is 
lifted, and a fulcrum obtained ; the biceps then acts and 
produces flexion. These motions, M. Robert, who has 
called attention to them, 1 says still exist in one of his 
patients, fifteen years after the operation, and are already 
apparent in another which is only convalescing ; they were 
also sufficiently distinct in a patient operated on by Dr. 
J. 0. Stone, of New York. 2 

It has been alleged that, as a rule, young persons do 
best after excision of the elbow ; there being in the adult 
a greater tendency towards anchylosis to overcome. 3 This 
statement is not supported by the cases under consideration. 
The ages of the patients whose elbows became anchylosed 
were 57, 31, 25, 17, 16, 13, 12, and 8. Taking eight of 
the oldest patients in the table, and whose ages were re- 
spectively 74, 68, 63, 61, 60, 57, 6Q, 52, the results will 
be found to have been, useful arms in three, aged 68, 63, 
56 ; anchylosis in one, aged 57 ; a flexible elbow but stiff 
fingers in one, aged 74; death from exhaustion at the 
end of four weeks in one, aged 52, and in six days in an- 
other, aged 61 ; amputation at the end of two weeks, and 
death from phthisis six weeks afterwards, in one, aged 
60. From this it would appear that anchylosis is not es- 
pecially to be dreaded on account of advanced years, but 
that the mortality increases with the age of the patient, 
as in most operations. 

The following table presents a summary of what has 
just been stated. 

It appears therefrom, that the percentage of mortality 
is 12.60, and of failures, i. e. deaths and amputations, 
25.20. Of this latter class, 9 excisions were of the right 
elbow, 6 of the left, and in 15 the side is not stated. 

1 Gaz. des Hop., Nov. 20, 1858. 

2 N. Y. Joura. of Med., May, 1851, p. 302. 

3 Lancet, Oct. 4, 1856. 



EXCISION FOR DISEASE. 



65 



No. of 
Cases. 


Sex. 


Side. 


Result. 


119 


80 Males. 

38 Females. 
1 Not stated. 


48 Right. 

25 Left. 

46 Not stated. 


C 77 Useful arms. 
89 Recovered 1 8 Anchylosis. 

( 4 Unsatisfactory. 

( 10 Recovered. 
15 Amputated < 2 Died. 

( 3 Not stated. 
15 Died. 



This is not materially different from the results of other 
collected cases. Thus, the table of M. Thore, who does 
not give the number of deaths, comprises 88 cases with 
20 failures (insucces), or 22.72 per cent. 1 Blasius gives 
90 cases with 10 deaths, 8 in which the result is not 
stated, and 2 in which the caries returned. 2 Subtracting 
the 8 cases without result, we have remaining 82 excis- 
ions and 10 deaths, or a mortality of 12.20 per cent. The 
mortality by O. Heyfelder's table is 11.18. 3 

According to Malgaigne, of 61 amputations of the up- 
per arm for disease, 24, or 39.09 per cent, died. 4 Dr. 
Gross, from the addition of several tables (94 cases and 
20 deaths), makes the mortality 21.24 per cent. 5 The 
sources from which the first of these statements is de- 
rived, and the manner in which the second is made up, 
comprising, probably, amputations for both traumatic and 
organic lesions, render them of little value for purposes 
of comparison with the table of excisions. They perhaps 
authorize the conclusion, that excision is less fatal than 
amputation, though they are inadequate to decide in what 
proportion it is so. 



1 De la Resection du Coude, p. 42. 

2 Beitrage zur Praktischen Chirurgie, cited in B. and F. Med.-Chir. Rev., 
April, 1851, p. 285. 

3 Operationslehre, u. s. w., p. 247. 

4 Arch. Gen. de Med., Avril, 1842. 

5 System of Surgery, (Philad. 1859,) Vol. I. p. 653. 



66 EXCISION OF THE ELBOW- JOINT. 



OPERATION AND AFTER-TREATMENT. 

The elbow may be excised by a variety of methods, the 
principal difference between which is in the incisions 
deemed proper. Perhaps the best is that of Langenbeck, 
of Berlin, consisting of a single straight incision carried 
along the inner border of the olecranon, and extending 
two inches above and below its extremity. 1 It possesses 
the merit of simplicity, and of allowing the ready ap- 
proximation of the edges of the incision without gaping 
of the wound. It is only objectionable on account of the 
liability of the skin to tear, whenever the soft parts are 
diseased or stiffened by infiltration, during the extreme 
flexion necessarily made in exposing the ends of the 
bones. It is, therefore, most applicable to excisions for 
traumatic cause. The addition of an external lateral in- 
cision, falling upon the centre of the longitudinal one, 
obviates the difficulty just named, and converts the op- 
eration into that described in the books as Jaeger's, 2 or 
Liston's. 3 

In the five operations performed by the Moreaus, loss of 
sensation in the little finger, numbness of the ring fin- 
ger, and wasting of the ulnar side of the hand, are de- 
scribed as having been constant accompaniments. These 
accidents, due to the division of the ulnar nerve, are said 
to have been first obviated by Dupuytren, 4 but Wachter, 
in 1810, had insisted upon the importance of its preser- 
vation intact. 5 The exposure of the joint should be so 
conducted that the sheath of the nerve, where it lies in 
the groove beside the olecranon, shall not be interfered 
with. The disorganization of the soft parts is sometimes 

1 A. Tobold, De Articuli Cubiti Resectione, (Berlin, 1855,) p. 13. 

2 Bourgery, Med. Oper., p. 216. 

8 Practical Surgery, (3d ed., London,) p. 156. 

4 Malgaigne, Med. Oper., (5 me ed., Paris,) p. 222. 

5 De Artie. Extirp., p. 77. 



OPERATION AND AFTER-TREATMENT. 67 

so great, that the position of the nerve can with difficulty 
be decided upon, and its place only determined after the 
bones have been partly laid bare ; the operation may, 
however, often be performed so that it is neither exposed 
nor seen. Although there is a possibility that sensation 
may be regained, even if the nerve has been divided, this 
ought never to be done, unless by accident, when preven- 
tion is so easy and a cure so doubtful. In compound 
fracture of the internal condyle, the nerve is liable to be 
severed by the accident itself. 

When the bones are fairly exposed, — and this, owing to 
the shape of the articulation, is a dissection requiring time, 
and one of no little difficulty, especially about the inner 
condyle, — division of the lateral ligaments and conjoined 
tendons freely opens the interior of the joint. 

In a large proportion of cases only the surface of the 
articulation is diseased, and that alone need be removed. 
The extent of the excision, however, should be such, that, 
when the parts are brought together, the bones shall nei- 
ther lock, nor the transverse incision gape, in bending the 
arm to a right angle. The insertions of the biceps and 
brachialis anticus muscles are to be preserved if possible, 
and it is to be remembered that, in dividing the ulna and 
radius low down, the interosseous artery is endangered. 

Four inches of bone above and four inches below the 
joint have several times been removed, and a useful arm 
left. Birne, cited by Velpeau, 1 describes a gun-shot wound 
of the elbow which carried away fourteen and a quarter 
inches of the bones, and yet the patient recovered with an 
interval of only fifteen lines between them, and could lift a 
weight of forty pounds. He raised his arm by a sudden jerk 
and a vigorous contraction of the muscles of the shoulder, 
and when the arm had been thus carried up, the fingers 
acted voluntarily. Without deciding whether such an 
amount of removal, intentionally done, is admissible, I 

1 Blackman's Edition, Vol. II. p. 457. 



68 EXCISION OF THE ELBOW- JOINT. 

content myself with expressing the opinion, that no precise 
limit can be fixed, but that the extent to which the bones 
may be excised is a question for the judgment of the sur- 
geon to determine in each case, upon its own merits and 
the circumstances which accompany it. Mr. Erichsen thinks 
that one of the chief dangers in the operation is the mye- 
litis liable to occur from opening the medullary canal of the 
humerus in dividing the bone high up. He has seen it 
take place in three instances. 1 Mr. Stanley speaks of a 
case where, apparently, this accident occurred with a fatal 
result. 2 The observation deserves attention, although in 
no instance does the occurrence appear to have taken place 
in the cases comprised in my table. 

In the excision of no joint for disease have partial oper- 
ations been so universally condemned as in that of the 
elbow. Without an exception, all surgeons who have of- 
ten operated decide against them. Among these may be 
mentioned Mr. Syme, Mr. Bickersteth, Mr. Erichsen, and 
Mr. Fergusson. The latter says : " Although not prepared 
to give a positive opinion on the subject, as far as my own 
experience goes, I am disposed to think that it is not 
doing justice to the patient to take away only one half of 
a joint in resection (of the elbow), and that it is better 
that the opposing articular surface should be removed at 
the same time." 3 M. Thore, in 1843, with his compara- 
tively limited experience, says : " Anchylosis never, or al- 
most never, follows excision of the elbow. When I say 
this, I mean complete excision, for the chances of anchy- 
losis are infinitely greater when one of the articulating 
surfaces is left." 4 

According to Blasius, already quoted (p. 65'), in 24 suc- 
cessful cases out of 28 partial excisions, 6 were cured with, 
and 10 without anchylosis ; the remainder were uncertain. 

1 Lancet, Oct. 4, 1856. 

2 On Diseases of Bones, (Am. ed.,) p. 38. 

3 Med. Times and Gaz., June 12, 1858. 

4 De la Resect, du Coude, p. 64. 



OPERATION AND AFTER-TREATMENT. 69 

In 48 cases of complete excision, anchylosis occurred but 7 
times. According to 0. Heyfelder, in 79 partial excisions 
for injury and disease, (no distinction being made between 
the two in his summary,) 8 died, 3 were amputated, 14 
became anchylosed, and 54 recovered with useful limbs ; 
this represents one failure in every 3| cases. On the other 
hand, in 207 complete excisions, 24 died, 7 were amputated, 
5 became anchylosed, and 171 regained useful limbs ; one 
failure in only 5| cases. 1 

In 21 cases of partial excision contained in the table 
on pages 58 et seq., 9 resulted in useful arms, 5 died, 3 
were subsequently amputated, 3 ended in anchylosis, and 
one at the end of 8 months remained unhealed and in an 
unpromising condition. Although these figures do not 
indicate that anchylosis is the most common accident of 
partial excision, they abundantly prove, so far as they go, 
the frequent occurrence of unfavorable results, since in 
these 21 cases is comprised one third of all the deaths inci- 
dent to the whole number (119) of excisions. 

With regard to the length of treatment necessitated by 
the operation, it will be found that months, or years, or 
even a whole life-time, may elapse before the occasional 
occurrence of small collections of matter in and about the 
joint will cease ; but these rarely interfere with the pa- 
tient's comfort, or affect the usefulness and strength of the 
limb. This is well illustrated by the case of a«nan, forty- 
five years old, entering Guy's Hospital under the care of 
Mr. Cock. His elbow had been excised eighteen years be- 
fore, by the late Mr. Aston Key ; he had had good health 
and excellent use of his arm all the time. His occupation 
being that of a letter-sorter, he had recently tried to work 
with his arm in a new and unaccustomed position ; an ab- 
scess formed, and Mr. Cock, on opening it, found it to be 
caused by a limited necrosis of the end of the humerus ; 
this he removed, together with some loose fragments, and 

1 Operationslehre und Statistik der Resectionen, p. 247. 



70 EXCISION OF THE ELBOW-JOINT. 

the man shortly after resumed his business. 1 In cases of 
recurrence of the disease, Erichsen advocates the resort to 
a second operation. Indeed, he mentions an instance in 
which he " excised the bones about the elbow for a third 
time with perfect success." The patient, a boy about four- 
teen years of age, obtained a most useful arm, " regaining 
the four movements of the joint, — pronation, supination, 
flexion, and extension." 2 

M. Thore observes, that even at an early period patients 
may commence the use of their arms, but only after the 
lapse of years does the limb attain the full measure of ease 
and perfection in its movements. " In general terms it 
may be said, that towards the end of the first or second 
year motion is sufficiently free, and the limb strong enough 
to be really useful." 3 

The " time under treatment " is recorded in 77 of the 
cases of recovery included in my table. This has refer- 
ence, not to the time when full usefulness of the limb 
was restored, but to the period during which the patient 
required surgical care, and at the end of which he was 
able to commence the use of his arm. This varies from 
4 weeks to 2 years, and averages 175 T 3 T days, or 5f months. 
According to Sansom, 110 days is the average duration of 
treatment after amputation of the arm. 4 



DISSECTIONS. 



In 1855, Mr. Syme, with all his experience, had seen but 
two dissections of elbow-joints after the lapse of any length 
of time from the excision. In one, the operation had been 
performed ten months ; in the other, which was followed 

1 Med. Times and Gaz., Oct. 24, 1857. 

2 Sc. and Art of Surg., (3d ed., London,) p. 706. 

3 De la Resect, du Coude, p. 67. 

4 Mortality after Operations of Amputations, (London, 1859,) p. 19. 



DISSECTIONS. 71 

by a most successful result, nine years had elapsed. In 
the first, " the place of the extremities of the bones was 
occupied by a mass of strong fibrous tissue, closely resem- 
bling ligament, which allowed of motions in all directions. 
The triceps was attached to the posterior surface of this 
newly-formed ligament, and, through means of it, to the 
extremity of the ulna." 1 In the second case, the ends of 
the bones were adapted to each other in such a way as to 
form a hinge-joint. There had been an extensive growth 
of bone and ligament, and the osseous surfaces of the new 
articulation were covered with a fibro-cartilage, or smoothed 
over by a porcellaneous deposit, and lubricated by a sort of 
synovia : the ulna and radius were received between two 
osseous processes growing downwards from the end of the 
humerus. 2 The drawing which accompanies this last de- 
scription presents a striking resemblance, with respect to 
these processes, to a specimen falling under my own ob- 
servation, taken from a man whose arm was amputated 
five months after excision of the elbow, and in which two 
cornua, projecting from the end of the humerus, were a 
marked and peculiar feature. In a case dissected by Mr. 
A. M. Edwards, of Edinburgh, six months after the excis- 
ion, there was fibrous union of the divided ends, and the 
specimen also exhibited some " nodules of bone at the 
lower end of the humerus, which the reporter suggested 
were rudimentary condyles of new growth." 3 

In a partial excision of the elbow, where the end of the 
ulna only was removed, the motions of the arm returning, 
at the end of nine months, " a bony process, resembling the 
olecranon, could be felt given off from the end of the ulna 
and connected with the triceps muscle, as could be easily 
made out in extending the arm." 4 

From the dissections collated by Albrecht Wagner, it 

1 On Excision of Diseased Joints, p. 91. 

2 Lancet, Mar. 3, 1855. 

8 Edinb. Month. Journ. of Med. Sc, Dec. 1860. 

4 T. Holmes, in New Sydenham Society's Publications, Vol. V. p. 233. 



72 EXCISION OF THE ELBOW- JOINT. 

appears that complete pseudarthrosis was found in but one 
case ; in this the trochlea of the humerus appeared as per- 
fect as if none of it had been taken away ; in all the others, 
the bones were either rounded, and united by a fibrous 
medium, or more or less completely anchylosed from mus- 
cular adhesions, the shortness or density of the uniting 
fibrous tissue, the too close approximation of the bones 
from muscular contractions, or the formation of a super- 
abundant callus. In no case had a new articular capsule 
been formed. The muscles had fixed themselves to the 
processes and irregularities of the bones which had been 
gradually developed, and were generally atrophied, or 
more or less fatty. The nerves were softened, enlarged, 
and also fatty, and to this degeneration he thinks the loss 
of power in the limbs may be attributable. 1 

In the first case dissected by Mr. Syme, the nerve, which 
had been completely divided at the time of the operation, 
was found perfectly reunited. 2 A similar case occurred 
to M. Roux. The ulnar nerve was not only divided, but 
a portion of it excised. The little finger and the ulnar 
side of the ring-finger were wholly deprived of feeling. 
A year later, sensation had entirely returned, and when, 
fourteen years after the operation, the patient was again 
examined, the sensation of one arm was equally perfect 
with that of the other. 3 Such results are probably of rare 
occurrence. 

The regeneration of the removed bone by preserving the 
periosteum is a question still in abeyance, and requires the 
confirmation of dissections not yet made. M. Verneuil, 
well known as a careful observer, presented several cases 
of excision of the elbow to the French Academy in 1859, 
to show that, by dissecting off and preserving whatever of 
periosteum the disease has left, the shortening ordinarily 

1 On the Process of Repair after Resection and Extirpation of Bones, New 
Syd. Soc, Vol. V. p. 121. 

2 On Excision of Diseased Joints, p. 92. 

3 De la Resect, du Coude, p. 78. 



CONCLUSIONS. 73 

ensuing might be obviated. Thus, in one case where four 
inches of bone were removed and this precaution taken, 
the shortening was but two inches. In another instance, 
a cylinder of periosteum was preserved with satisfactory 
results. 1 



CONCLUSIONS. 



It may be concluded from what has been said in the 
preceding pages, — 

First. That although partial excision had been practised 
upon several occasions, and by Mr. Wainman, in England, 
so early as 1758-59, the first complete excision of the 
elbow-joint was performed by the elder Moreau, in 1794. 

Second. That excision for traumatic cause appears to 
be a safer operation than amputation, and ordinarily pre- 
serves a limb of very considerable usefulness. This is 
especially true of those occurring in civil practice. 

Third. That excision for anchylosis is only adapted to 
cases where the arm has stiffened in a straight position, 
or in one of extreme flexion, unless special circumstances 
authorize the risk of an operation frequently ending in 
no improvement of the anchylosis. 

Fourth. That in excision for disease, death occurs once 
in 7-rf cases ; and that the operation fails of its primary 
intention, — the riddance of the disease with the preser- 
vation of a useful arm, — by death, amputation, or other 
cause, once in 3£{ cases. Patients recovering are usually 
able to resume their ordinary occupations. 

Fifth. That partial excision, either for traumatic or 
organic lesions, is a frequent cause of unfavorable results. 

1 Arch. Gen. de Med., Janv. 1860, p. 107. 



74 EXCISION OF THE WKIST-JOINT. 



WRIST-JOINT 



HISTORY. 



The earliest approach to this excision is to be found in 
the " Cases and Practical Remarks in Surgery " of Ben- 
jamin Gooch, published in 1758, where Mr. Cooper, of 
Bungay in England, is reported to have " succeeded ,to 
his wish in sawing off the head of the radius, which passed 
through and made a dismal laceration of the tendons at 
the wrist, and the patient found little or no defect in the 
strength or motion of the joint. " Mr. Gooch adds, " I 
have also succeeded beyond my expectation in cases of 
this nature, by the same practice." (p. 104.) M. Bagieu, 
at about the same period as in the preceding instance, 
removed the comminuted bones of the wrist-joint, crushed 
and disintegrated by a gun-shot injury ; anchylosis followed, 
and the fingers were left so flexible, that the patient, a sol- 
dier, aged twenty-five, was able to write and draw, and re- 
tained to a very considerable extent the shape of the hand. 1 

In 1773, Mr. Orred, of Chester, sawed off, for a disease 
which was probably necrosis, more than three inches of the 
ulna ; 2 and about the same period, Bilguer, as it appears 
from Wachter, did the same in a case of injury. 3 But these 
can hardly be classed amongst excisions of the wrist-joint. 

In July, 1794, the elder Moreau excised the wrist, for 
acute necrosis, in a man aged seventy-one, who had already 
lost his other hand from a similar cause ; on the 29th of the 
same month the case terminated fatally, from the intensity 
of the primitive inflammation. Subsequently, the younger 
Moreau operated for caries upon a female, who, in the 
end, recovered sufficiently to resume her occupation of a 

1 Examen de plusieurs Parties de la Chirurgie, Tom. II. p. 446. 

2 Philos. Trans. Lond., Vol. LXIX. p. 6. 
8 De Artie. Extirp., p. 19. 



HISTORY. 75 

seamstress. M. Roux was also an early operator, two in- 
stances being on record of its performance by him ; one 
case, in which the end of the radius only was excised, 
required subsequent amputation, of which the patient 
died ; the other resulted more satisfactorily. 1 

In 1800, M. St. Hilaire, of Montpellier, removed the 
ends of both radius and ulna for a compound dislocation 
with perfect success. The same was afterwards done by 
M. Hublier, of Provins, in 1828, for a compound disloca- 
tion, with rupture of the tendons, and by MM. Huguier 
and Rossi for gun-shot wounds. 1 

In 1839, Dietz removed the ends of the radius and ulna, 
and all the carpal bones, for caries in a man aged forty. 
A return of the disease rendered amputation of the arm 
necessary four years afterwards. 2 

These cases, scattered in periodicals and articles in En- 
cyclopaedias, seem to have attracted but little attention, 
and the operation appears not to have been performed 
again until reintroduced by Mr. Fergusson in London, 
August 16, 1851. 3 

Dr. Lewis A. Sayre, of New York, performed a partial 
excision of the wrist in December, 1853. He desired to 
remove both rows of carpal bones, but was dissuaded by 
his colleagues in the hospital. To this he attributes his 
failure, subsequent amputation having been found neces- 
sary. 4 According to Dr. Blackman, the wrist has also 
been excised by Dr. Carnochan ; and Prof. Pancoast has 
removed the upper row of carpal bones. 5 

The wrist-joint has been excised both for traumatic 
cause and for disease. 

1 Diet, des Sc. Med., Art. Resection; Diet, en 30 Vol., Art. Poignet ; 
Blackman's Velpeau, Vol. II. p. 448 ; Bulletin des Sc. MeU, Vol. XVII. 
p. 398 ; L. Champion, Traite de la Resection des Os Caries (Paris, 1815). 

2 Ried, ueber Resectionen, p. 364, cited by 0. Heyfelder, p. 262. 

3 Lancet, Jan. 28, 1854. 

4 N. Y. Journ. of Med., May, 1854, p. 443. 

5 Blackman's Velpeau, Vol. II. p. 449. 



76 EXCISION OF THE WRIST- JOINT. 



EXCISION FOR INJURY. 



No special rule as to the adaptability of this particular 
excision to military surgery can be deduced from its per- 
formance after a gun-shot injury by M. Bagieu, 1 from the 
cases of MM. Huguier and Kossi, or from the three in- 
stances operated on in the Crimea, with one fatal result. 2 

Equally impossible is it to draw any conclusive deduc- 
tion from the cases of compound dislocation of Cooper of 
Bungay, St. Hilaire, Hublier, Adelmann, and Beck, or 
from the compound fractures of Bied and Just; 3 yet all 
of these were satisfactory in their results, with the excep- 
tion of Beck's, which proved fatal. From all these facts 
together, it would seem, however, that excision of the 
lower end of the radius is an operation well suited for 
traumatic cases, especially when it is remembered that 
the hand, preserved in the most imperfect condition, is 
so great a gain over its entire loss. 

Sir Astley Cooper, with only partial success, once ex- 
tracted the scaphoid bone of the wrist for a compound 
dislocation, and he lays down the rule, that, when one 
or two of the carpal bones are dislocated, they may be 
removed ; but if the injury is more extensive, amputa- 
tion is necessary. 4 Malgaigne mentions the successful re- 
moval of a semi-lunar bone under similar circumstances, 
but with reference to excision says, that the "fabulous 
result announced by Grooch and Cooper is not to be hoped 
for." 5 

1 Diet, en 30 Vol., Art. Poignet. 

2 Med and Surg. Hist, of the Brit. Army which served in Turkey and the 
Crimea, Vol. II. p. 377. 

3 Heyfelder, Operationslehre und Statistik der Resectionen, p. 270. 

4 Disloc. and Fract., (Am. ed.,) p. 436. 

5 Tr. des Luxations, (Paris, 1855,) pp. 711, 718. 



EXCISION FOR DISEASE. 77 



EXCISION FOR DISEASE. 

I am aware of no case of excision of the end of the 
radius, or of any part of the wrist-joint, for malignant 
disease. 

A specimen presented by M. Velpeau, of Paris, to the 
late Dr. John C. Warren, of Boston, who assisted in its 
removal by that distinguished surgeon, exhibits what ap- 
pears to be a chronic inflammation of the extremity of the 
radius, without caries or implication of the articulation. 
No history accompanies it, nor is the result of the opera- 
tion recorded. 

The case operated on by Moreau for necrosis, and al- 
ready alluded to as terminating fatally ; another by Oskar 
Heyfelder, for a necrosis following a compound fracture 
which required amputation in twenty days, and resulted 
in death from pyaemia in nine more; 1 and one related 
by Champion, 2 where a countryman, long the subject of 
necrosis of the end of the radius, cut the bone off himself 
with a carpenter's chisel, and recovered with a hand un- 
able to hold the lightest thing, do not offer encouraging 
precedents for other operations of the sort. 

In cases of caries and white swelling, a larger, but still 
a limited experience, presents itself for consideration. The 
articulation of the wrist is not one of those most frequent- 
ly diseased ; — according to the records of Guy's Hospital, 
in only four per cent of all cases of diseased joints. 3 

Under the term " excision of the wrist, or radio-carpal 
joint," must be included not only the removal of what 
strictly constitutes that articulation (radius and first row 
of carpal bones), but all operations which excise a part 
or the whole of the ends of the radius and ulna, a part 

1 Operationslehre und Statistik der Resectionen, p. 269. 

2 Tr. des Os Caries, p. 57. 

3 Bryant, Dis. and Inj. of Joints, p. 136. 

7* 



78 EXCISION OF THE WRIST- JOINT. 

or the whole carpus, the proximal ends of the metacar- 
pal bones, or all of these at once. Such an extensive re- 
moval is, however, rarely attempted, and the excisions 
practised in this locality are almost uniformly partial. 

The surgeon naturally hesitates before undertaking an 
operation so difficult of execution, and one in which he 
can hardly fulfil the first law of excisions ; viz. that, to- 
gether with the partial or complete removal of the articu- 
lar extremities of the bones, there shall be a free exposure 
or destruction of the synovial cavity of the joint. " Any 
operation," says an able writer in the British and For- 
eign Medico-Chirurgical Review, 1 " which leaves the ar- 
ticulation in a condition approaching to that of a wounded 
joint, will lead to no good result, but will, rather thence- 
forth be exposed to the dangers attendant on joint-wounds, 
and will terminate as such accidents are wont to do." 

The inherent anatomical peculiarities of the radio-car- 
pal and carpal articulations in the intercommunication of 
their synovial surfaces, of necessity render any excision 
which does not remove everything between the extremity 
of the radius and the ends of the metacarpal bones inclu- 
sive — the articulation of the thumb with the trapezium 
alone excepted — liable to the disadvantages just men- 
tioned. For, in anything short of this, synovial surfaces 
must be left exposed, from which inflammation, suppura- 
tion, and ulceration of the cartilages will be liable to 
originate. 

What prospects of success this excision holds out, the 
following quotations may serve to exhibit. 

Mr. Fergusson, in 1857, says that he has, during the 
previous five years, excised the whole of the carpus four 
times. " But I am yet somewhat sceptical as to the results 
of such an operation. One patient preferred amputation 
to further delay ; one died of consumption With the si- 
nuses not yet closed ; a third died of disease of the lungs 
and other ailments, with the wrist all but well ; and the 

1 Oct. 1857, p. 229. 



EXCISION FOR DISEASE. 79 

fourth, after protracted distress, ultimately died of phthisis. 
Within the above period, Mr. Stanley, of St. Bartholo- 
mew's, has removed a diseased carpus with, I believe, very 
satisfactory results. Of all the principal excisions associ- 
ated with modern surgery, this is the one on which I have 
the least reliance ; yet I think it worthy of further trial, 
for in whatever state the hand might be left, I believe it 
would prove more valuable than any artificial substitute." 1 

The writer in the British and Foreign Medico-Chirurgi- 
cal Review, already cited, sums up 15 excisions for dis- 
ease, — excluding operations on the carpus, not involving 
the wrist-joint, — as follows : 3 patients died, and 5 recov- 
ered with more or less useful hands ; 3 were in progress 
of cure ; whilst of 3 others the prospect for one was 
" hopeful," one " had some chance of recovery," and one 
was " unsatisfactory." The remaining patient, a man sixty- 
two years old, never had any use of his hand, though the 
wounds healed. The operators in these cases were Mo- 
reau, J. F. Heyfelder, Fergusson, Dr. Green of Bengal, 
Erichsen, Simon, Stanley, Butcher, Cock, and Page. 2 

The following table contains the above cases, together 
with such additional ones as have been published. Though 
their number is not large, the result in many not at- 
tained, and the extent to which the excisions were car- 
ried of very considerable variety, it still furnishes us, 
imperfect as the details are, with a tolerable opportunity 
to form definite opinions of the operation in question. 

The table comprises memoranda of 39 cases ; in 24 the 
patients were males, and in 12 females, the sex not being 
stated in 3 ; in 6 the excisions were of the right hand, and 
in 4 of the left, the side not being noted in the remainder. 
The age of the oldest patient is 62, and of the youngest 
12 years. The former recovered with hardly any use of 
the hand; the latter, with tolerably good motion in the 
wrist and fingers. 

1 Pract. Surg., (4th ed.,Lond.,) p. 294. 

2 Oct. 1857, p. 231. 



80 



EXCISION OF THE WRIST- JOINT. 



No. 

1 


Sex. 
F. 


Age. 


Treatment. Extent of Excision. 


28 


6 mos. 


Extremity of ulna and four carpal bones. 


2 


F. 


58 


7 days. 


Ends of radius and ulna. All the carpal bones ex- 
cept trapezium. Right hand. 


3 


M. 


62 


6 mos. 


Ends of radius and ulna. All the carpal bones. 


4 


M. 


32 


4 mos. 


All the carpus except trapez. and pisiform. R. hand. 


5 


M. 


13 


Some w'ks. 


All the carpus except trapezium. 


6 


M. 


19 


1 year. 


All the carpus except trapez. and pisiform. L. hand. 


7 


F. 


20 


1 year. 


End of radius, trapezium, scaphoid, and semilunar 
bones. Left hand. 


8 


F. 


40 


6 mos. 


Not stated. 


9 


M. 


44 


2 mos. 


Five carpal bones. 


10 


M. 


36 


6 mos. 


Ends of radius and ulna. Trapezoid, scaphoid, cu- 
neiform, magnum, semilunar. 


11 


M. 


22 


5 mos. 


All the carpal bones except trapezium. 


12 


M. 




5 mos. 


All the carpal bones. Two operations performed. 


13 


M. 


34 


2 mos. 


Ends of radius and ulna ; entire carpus ; ends of 
metacarpal bones. Right hand. 


14 


F. 


28 


45 days. 


Ends of radius and ulna. First row of carpal bones. 
Right hand. ' 


15 


M. 


30 




Ends of radius and ulna. All the carpus except the 
trapezium. 


16 


M. 


20 


21 y'rs. 


Two thirds of 4th and 5th metacarpal bones ; cunei- 
form, unciform, magnum, and trapezoid. R. hand. 


17 


F. 


31 


3 mos. 


" Joint resected and several carpal bones removed." 


18 


M. 


28 


8 mos. 


End of radius and most of the carpal bones. 


19 


M. 


12 


18 mos. 


Ends of 1st, 2d, and 3d metacarpal' bones ; trapezi- 
um, trapezoides, and magnum. Left hand. 


20 


F. 


30 


1 year. 


Remnants of os magnum and rough surfaces of sur- 
rounding bones. Left hand. 


21 


F. 






End of radius. 


22 


M. 


21 




Trapezium, magnum, unciform, and pisiform. 


23 








One row of carpal bones. 


24 








End of radius. 


25 


F. 


42 


1 month. 


Ends of radius and ulna. 


26 


M. 


18 






27 


M. 




84 days. 


Entire carpus. 


28 


M. 


59 


10 weeks. 


End of ulna, cuneiform, and pisiform bones. L. hand. 


29 






6 mos. 


Ends of radius and ulna. 


30 


F. 


14 




All the carpal bones. 


31 


M. 


40 




Ends of radius and ulna ; all the carpal bones. 


32 


M. 


35 


3 weeks. 


Ends of radius and ulna ; all the carpal bones. 


33 


M. 




1 year. 


Ends of radius and ulna ; all the carpal bones. 


34 


F. 


20 




Ends of radius and ulna ; two carpal bones. 


35 


M. 


25 




Ends of radius and ulna. 


36 


F. 


19 




Ends of radius and ulna. 


37 


M. 


29 




End of radius. 


38 


M. 35 




All the carpal bones. 


39 


M. 1 39 


1 year. 


All the carpal bones and bases of all the metacarpal 
bones. 



EXCISION FOR DISEASE. 



81 



Result. 



Did well, and some motion obtained. 
Died comatose. Sinuses and veins of brain 

and membranes engorged with blood. 
"Not much use of hand." 
Much doubt whether hand will be saved. 
Excellent use of hand and fingers. 
Died of " continued fever." Parts unhealed. 

Stiff wrist, but useful fingers. 

Stiff wrist and fingers. 

Amputated. 

Died of phthisis. No anchylosis was in 
progress. 

Died of phthisis 19 months after operation. 

Amputated for disease of the soft parts. 

Useful hand. Considerable mobility of 
fingers. 

Left the hospital with the wound still dis- 
charging. 

Healing slowly and sent into the country. 

Use of thumb perfect ; writes with ease ; 
motion of fingers considerable. 

" Recov'd, but hand is not a promising one." 

Some prospect of motion. 

Flexion and extension of hand good. Pha- 
langes of fingers have tolerable motion. 

Anchylosis and limited motion of fingers. 
Able to sew. 
Doing well. 

Subsequently amputated. 
Subsequently amputated. 
" Nearly well." 

Some sinuses when made an out-patient. 
Amputated. 

At end of five years quite free use of hand. 
Amputated for returning disease. 
" Almost unimpaired prehension." 
Amputation at end of four years. 
Wound healed ; motion and sensation re- 
Died from phthisis. [turned. 
No pronation or supination. Tendency 

to lateral displacement. 
Amputated. 

Recovered. Useful hand. 
Died. 
Recovered. Useful hand. 

" Almost as useful as before the disease." 



Authority. 



Med. Times & Gaz., Mar. 21, 1857. 

Dublin Quarterly, Nov. 1855. 
Med. Times & Gaz., May 3, 1856. 
Lancet, Aug. 25, 1855. 
Ibid., Mar. 17, 1855. 
Ibid., Jan. 28, 1854. 

Med. Times & Gaz., May 20, 1 854 
Ibid., Nov. 4. 1854. 
Ibid., Sept. 23 and Oct. 21, 1854. 
Ibid., Nov. 1, 1856, and Lancet, 

Oct. 18, 1856. 
Lancet, Jan. 28 and Mar. 11, 1854. 
Ibid., Apr. 3, 1858. 
Med. Times & Gaz., Apr. 14, 1860, 

Sc. & Art of Surg., 3d ed., p. 707. 

Lancet. Jan. 21, 1854. 

Med.Times & Gaz., Apr. 14, 1860. 
Dublin Quarterly, Nov. 1855 and 

Feb. 1859. 
Med. Times & Gaz., Feb. 7, 1857. 
Lancet, Jan. 28, 1854. 
Schillbach, Resect, der Knochen, 

Part II., p. 216. 

Ibid., p. 224. 

Diet, des Sc. Me'd., Art. Resection. 
Charleston Med. J. & R., July,l 858, 
N. Y. Journ. of Med., May, 1854. 
Diet, en 30 Vols., Art. Poignet. 
Journ. Hebd. de Med., Vol. 8, p. 214 
Med. Times & Gaz., May 8, 1858. 
Arch. Gen.de Med., [5.] T.2,p. 733 
J. F.Heyfelder, Res. u. Amp., p.l 50 
New Sydenh. Soc., Vol. V. p. 237. 
Am. Med. Times, Sept. 22, 1860. 
O. Heyfelder, Opera'lehre, p. 262. 
Ibid., p. 263. 
Ibid., p. 272. 

Ibid. 

Ibid. 

Ibid. 

Ibid., p. 273. 

Ibid., p. 274, 

Bost. M. & S. Journ., June 27, 1 861 , 



82 EXCISION OF THE WKIST-JOINT. 

In these cases there were 17 recoveries. In 14 a more 
or less serviceable hand was regained, whilst in 3 it re- 
mained entirely useless ; 6 patients died ; 8 underwent 
subsequent amputation; and in 8 a definite result had 
not been reached. 

Of the 6 fatal cases, 3 were from phthisis ; one (No. 10), 
at the end of 6 months, no anchylosis being in progress; 
a second (No. 11), at the end of 19 months, the parts 
being still open and discharging badly 7 months after the 
operation; the third (No. 33), at the end of a year, but 
the condition of the wound is not stated. The fourth 
patient (No. 2), fifty-eight years old, died of "coma" at 
the end of seven days; the fifth (No. 6), of "continued 
fever" at the expiration of a year, the parts being un- 
healed; in the sixth (No. 37), the cause of death is not 
mentioned. 

The 8 cases unsettled as to their result were in the fol- 
lowing condition, respectively: — 

1 after 4 months, doubtful if the hand would be saved. 

1 after 45 days left the hospital, with the wound still 
discharging. 

1 after was healing slowly. 

1 " 8 months some prospect of motion. 

1 "1 month nearly well. 

1 " 3 weeks doing well. 

1 " doing well. 

1 " still discharging. 

In other words, 7 held out some prospect of satisfactory 
recovery, and one patient, at the end of 4 months, was 
likely to lose the hand. So that, summing up the whole, 
it appears that there were 



f 6 died. 
14 good results ; 7 unsettled as to result ; 18 failures. J ® ^f^w 



useless hands, 
unpromising. 



Of the cases in which the result was an unfavorable 
one, 2 were of the right wrist, 2 of the left, and in 14 
the side is not stated. 



OPERATION AND AFTER-TREATMENT. 83 

The cases given prove, I think, that the greater or less 
extent of the excision does not affect the result; those 
where only a few carpal bones were extracted doing as 
well as when the whole carpus, with the ends of the ra- 
dius and of the metacarpal bones, was removed. And 
although many patients recover with useful hands, — as, 
for instance, in No. 16, where the patient was able to 
write and move his fingers in a very satisfactory manner, 
and in Nos. 13, 19, 28, 30, and 39, where the motion of 
the fingers, and in one of the wrist, was wholly regained, 
— still, when 18 failures are set against 14 successes, and 
7 unfinished, though promising cases, with an average 
length of treatment in 11 of those recovering — where 
this is recorded — of 278 days, or more than 9 months, 
the operation, even if the mortality is not very great, 
must be one which should be performed only under 
exceptional circumstances. 



OPERATION AND AFTER-TREATMENT. 

In the dissecting-room it is by no means difficult to ex- 
cise the wrist-joint, and yet respect the tendons which lie 
in close relationship to it ; but upon the living subject it 
is not an easy thing to do, when these are surrounded by 
diseased tissues. To obviate this difficulty, Mr. Simon, 
of St. Thomas's Hospital, proposes and has operated by 
longitudinal, palmar and dorsal incisions, so that access 
to the joint may be had between the tendons thus sep- 
arated; 1 these incisions, however, must be very long to 
permit of removing the bones, and the palmar one, to be 
of any benefit, must divide the deep flexor tendons, which, 
it will be remembered, opposite the articulation, are com- 

1 Lancet, Jan. 14, 1854. 



84 EXCISION OF THE WRIST-JOINT. 

bined and not separated for the different fingers. Others, 
considering the preservation of tendons glued down and 
matted together by long disease as unimportant, have 
attacked the joint by a transverse or concave dorsal 
incision. It is doubtful if those cases in which so much 
pains are taken to preserve the tendons turn out more 
useful in their result than those performed by this last 
method. Mr. Stanley operated in this way, and with a 
very successful result (No. 5) ; and its success might be 
inferred from Cooper's and M. Hublier's cases, where, 
though the tendons were ruptured, the hands were after- 
wards used with considerable facility. 

Mr. Fergusson at first operated by longitudinal incis- 
ions along the ulnar and radial borders of the wrist, but 
subsequently considered a single one of tolerable length, 
along the ulnar side, to be sufficient ; especially as that 
on the radial side must, almost of necessity, cut off the 
radial artery where it winds round the head of the meta- 
carpal bone of the thumb. 1 

Mr. Butcher urgently advises the preservation of the 
trapezium and the extensor tendon of the thumb. 2 The 
trapezium, it is true, has a separate synovial cavity at its 
articulation with the metacarpal bone, and mobility of the 
thumb is doubtless of great importance ; but, under the 
circumstances, just how much its preservation, or that of 
the tendon, will contribute to this end, requires more 
proof than the single successful case (No. 16) which the 
Dublin surgeon adduces. 

The saw is almost inapplicable to this excision, and dis- 
eased bone is most easily extracted by strong forceps, or 
eaten away piecemeal by the gouge-forceps ; this may often 
be done by simply dilating already existing fistulas, without 
any formal incisions. 

Subsequently to the operation, the fingers, as well as 
the thumb, should be kept semi-flexed, so that, if any 

1 Pract. Surg., (4th ed., Lond.,) p. 294. 

2 Dublin Quarterly Journal, Nov. 1855. 



DISSECTIONS. 85 

motion is retained, their approximation may be more easily 
accomplished. 

The after-treatment in other respects is conducted upon 
general principles. 



DISSECTIONS. 



The preparations in museums encourage the hope that 
in many instances Nature will effect a result almost, if 
not quite, equal to any following the most successful op- 
erations. Specimens of complete anchylosis of the carpus 
are to be found in the Warren Museum, Boston, as well 
as in those of Berlin and Ley den, the Royal College of 
Surgeons, Bartholomew's and Guy's Hospitals. 1 These 
certainly indicate that reparative processes may be set up, 
sufficient in some cases for the preservation of the limb 
without an operation. 

Karl Textor examined the parts in an arm which he 
amputated eighty-four days after the excision of the entire 
carpus. The cavity left by the removal of the bones was 
filled with red granulations, whilst its walls were formed 
by the remains of the ligaments and the soft parts. The 
ulnar and median nerves terminated in the cicatricial mass 
by slight swellings. The tendons were intact, the deep 
flexors being united with the periosteum of the metacar- 
pal bones and the cicatrix of the wound. Two other cases 
of dissection are mentioned by Mr. Holmes in his transla- 
tion of Wagner, where also the above case is recorded, 2 
but their details amount to absolutely nothing. These 
three are all of which I have any knowledge. 

It appears from one of Schillbach's cases, that a com- 
pensatory enlargement sometimes occurs in the end of 

1 Cyclop, of Anat. and Phys., Art. Wrist. 

2 New Sydenham Soc, Vol. V. pp. 138, 237. 



86 EXCISION OF THE WRIST-JOINT. 

the ulna to make up for the bones removed by the excis- 
ion, the styloid process of this bone being enlarged three- 
fold, and causing a lateral displacement of the hand. 1 This 
latter deformity was also apparent in the patient whose 
case is reported by Champion, and who operated on him- 
self for necrosis of the end of his radius ; the want of 
support for the carpus having pulled the hand away from 
the ulna, and given it a most unfortunate twist. A ten- 
dency to the same thing was also manifested in a case of 
excision of the ends of the radius and ulna, operated on, 
in 1857, by a Russian surgeon named Scymanowsky. 2 



CONCLUSIONS. 



It may be concluded from what has preceded, — 
First. That the earliest excision of the wrist-joint was 
a partial one, (complete excision, even in subsequent times, 
being an exceptional event,) performed by Mr. Cooper of 
Bungay, England, some time previous to 1758. 

Second. That, in the present state of our knowledge, 
excisions of the wrist-joint, whether partial or complete, 
being followed by a large proportion of failures, requiring 
a very long treatment, and, when successful, the usefulness 
of the hand being so limited, are operations not sanctioned 
by sound judgment or conservative surgery. 

1 Beitrage zu den Resectioneu der Knochen, (Jena, 1859,) p. 223. 

2 Heyfelder, Operationslehre und Statistik der Resectionen, (Wien, 1861,) 
p. 263. 



EXCISION OF SMALL JOINTS OF THE HAND. 87 



SMALL JOINTS OF THE HAND. 



I know of only two instances of the excision of a meta- 
carpophalangeal articulation for injury, although others 
have doubtless occurred. In the first, a ramrod, shot 
through the hand, had broken off the head of the third 
metacarpal bone ; this was removed, and two months after- 
wards the patient was discharged with perfect use of the 
finger, though it was shortened to the length of the index 
and ring fingers. 1 In the second case the injury was from 
a circular saw. The joint of the index-finger was commi- 
nuted, but, the tendons being left intact, excision was per- 
formed in preference to amputation. The operation was 
followed by grave accidents, but terminated in recovery at 
the end of fifteen months ; the finger regained complete 
mobility, good strength and sensation, and was shortened 
only three fourths of an inch. 2 

In four cases of excision for caries, performed by Fricke 
of Hamburgh, three of which were practised upon the meta- 
carpal joint of the thumb, and the other upon the meta- 
carpal joint of the middle finger, three were successful. 
Two of those where the joint of the thumb was excised 
resulted in the complete restoration of its usefulness ; and 
the patient, the joint of whose middle finger was removed, 
was fast improving when he left the hospital. In the re- 
maining case the wound healed slowly, and the patient was 
discharged at the end of three months in rather an unsatis- 
factory state. 3 

In another case, where the head of the metacarpal bone 

1 Schillbach, op. cit., p. 235. 

2 Petruschky, De Eesect. Artie. Extrem. Sup., p. 37. 

3 Dublin Quarterly Jc-urn., May, 1837, p. 417. 



88 EXCISION OF SMALL JOINTS OF THE HAND. 

of the index-finger, together with that of the correspond- 
ing phalanx, was excised for disease, retraction had taken 
place to a level with the last joint of the middle finger 
three years afterwards, and some mobility existed at the 
point of excision ; active motion was slight, but passive was 
greater. The hand was a useful one in the patient's work 
as a laborer. 1 

A condition such as that last described is probably as 
favorable as any likely to result from excision of the meta- 
carpo-phalangeal articulations. The cases of Fricke are 
obviously reported too soon to be of much value. Both 
here and in the phalangeal articulations the contingency of 
anchylosis is to be considered, and the patient's profession 
taken into account. The tendons must almost inevitably 
become involved in the inflammatory and suppurative pro- 
cesses which ensue upon the injury or the excision, and 
either slough away, or remain so adherent that no mobil- 
ity, effected merely by passive flexion of the false joint, 
can be of any use to the patient. The operation may leave 
a finger enabling a clerk to hold a pen, but one which 
would be in the way of a carpenter every time he used his 
saw or his plane, and perhaps finally lead him to solicit its 
amputation. 

Excision of the ends of the phalangeal bones of the fin- 
gers in compound dislocations is a comparatively frequent 
operation, their reduction being sometimes accomplished 
only by such a step. Benjamin Gooch appears to have 
been among the first to adopt this course, he having thus 
operated upon the thumb of a seamstress in the middle of 
the last century. 2 

Even here, as in the larger joints, reduction without ex- 
cision seems to be not unattended by danger, since in three 
cases thus treated by Cramer, 3 Dickenson, 4 and Dr. Norris 

1 Schillbach, op. cit., p. 228. 

2 Cases and Pract. Kemarks in Surg., (2d ed., Norwich, 1767,) Vol. II. p. 324. 

3 0. Heyfelder, op. cit, p. 59. 

4 Med. Times and Gaz., 1857, p. 229. 



EXCISION OF SMALL JOINTS OF THE HAND. 89 

of Philadelphia, tetanus ensued, and in one of Samuel 
Cooper's, death took place within a week of the reduction, 
from the violence of the inflammation which followed. 1 In- 
tense inflammation of the whole fore-arm, sloughing, and 
finally amputation of the thumb, not infrequently occur. 
Sanson, Hey, Seutin, and others, speak of such cases. Mal- 
gaigne, however, in condemning operative interference, at- 
tempts to show that these occurrences are due rather to 
the lateness of the date, after the dislocation, at which re- 
duction was effected. The accident itself, as well as the 
operation, undoubtedly tends to the development of grave 
sequelae ; but there is as little doubt, that excision, though 
often unnecessarily performed, is far better practice than 
either amputation or non-reduction. 

Motion in the metacarpo-phalangeal joints, or in those 
of the proximal phalanges, is of more importance than in 
the other articulations ; for if the proximal joint be stiff, 
no amount of motion in the distal can be of service ; but 
if the proximal joint can be bent, a very small degree of 
mobility in the distal makes the finger a useful one. 

8 Am. Journ. of Med. Sc, Jan. 1843, p. 16. 



8* 



EXCISIONS OF THE LOWER EXTREMITY, 
HIP-JOINT. 



HISTORY. 



In 1730, John Daniel Schlichting dilated a fistulous 
opening over the hip of a young girl, aged fourteen, long 
the subject of hip-disease, and through it extracted the 
whole head of the femur; the recovery was complete, 
and, to quote from his report, " sex septimanarum curri- 
culo consolidat ut puella postmodum libere liceat manca 
incesserit." 1 

The first suggestion, however, of excision of the hip- 
joint is to be found in the Philosophical Transactions of 
the Royal Society of London for the year 1769, where 
Mr. Charles White of Manchester records the fact, that 
he has frequently " made an incision on the external side 
of the hip-joint, and continued it down below the great 
trochanter, when, cutting through the bursal ligament 
and bringing the knee inwards, the upper head of the os 
femoris hath been forced out of its socket and easily sawed 
off." " I have no doubt," he goes on to say, " but this 
operation might be performed on the living subject with 
great prospect of success." 

In 1783, Mr. Joseph Brandish published a case where 
the head of the femur, shattered by a charge of shot, ex- 
foliated away in fragments, and recovery ensued. 2 

i Phil. Trans., Vol. XXII. p. 270. 

2 Lond. Med. Journ., Vol. VII. p. 138. 



HISTORY. 91 

Allusion has already been made to the experiments of 
Yermandois (p. 3), performed upon animals in 1786, 
which were undertaken with a view to the substitution 
of excision for disarticulation at the hip. 

In 1816, Schmalz, of Pirna in Saxony, imitated suc- 
cessfully the example of Schlichting, in a case of similar 
character. 1 

Yet with these repeated hints, no real excision of the 
joint, or of the head of the femur, appears to have been 
performed until April, 1822, when Mr. Anthony White, 
of Westminster Hospital, London, (whose name is often 
confounded with that of Mr. Charles White above re- 
ferred to,) successfully removed the head and neck of 
the femur from a boy nine years old. 2 

In 1823, the operation was performed by Mr. Hewson, 
of Dublin ; 3 in 1829, by Oppenheim, for a gun-shot wound ; 4 
in 1832, at the siege of Antwerp, by M. Seutin ; 5 in 1834, 
by Kajetan Textor; 6 in 1836, by Sir Benjamin Brodie; 7 
and in 1838, 1839, and 1845, again by Textor. 8 

In 1845, it received an impetus from its adoption by Mr. 
Fergusson of London, the influence of whose position and 
example has made it during the last fifteen years a com- 
paratively frequent operation. " Whatever merit or de- 
merit," he says, "there may be regarding its revival in 
this country, since Anthony White's case, must be attrib- 
uted to me." 9 

In February, 1847, it was performed for the first time 
in France, by M. Roux. 10 

1 S. Oppenheimer, Ueber die Resection des Hiiftgelenkes, (Wurzburg, 1840,) 
p. 21. 

2 South's Chelius, Vol. II. p. 979. 

3 W. Hargrave, Syst. of Op. Surg., (Dublin, 1831,) p. 514. 

4 Gaz. Med., 1835, p. 183. 

5 A. Paillard, Relation Chirurg. du Siege d'Anvers (Paris, 1832). 

6 Karl Textor, Der zweite Fall von Aussagung des Schenkelkopfes, u. s w., 
(Wurzburg, 1858,) p. 15. 

7 Med.-Chir. Trans., Vol. XXVIII. p. 526. 

8 Textor, he. cit. 

9 Lancet, Aug. 14, 1852. 

i° Gaz. des Hop., Mar. 9, 1847. 



92 EXCISION OF THE HIP-JOINT. 

In the United States, Dr. Henry J. Bigelow of Boston 
first excised the head of the femur, February 21, 1852. 1 

The head of the femur has been excised for gun-shot 
injuries, and, either alone or with more or less of the ace- 
tabulum, for disease ; also, it is said, a single time, by Car- 
michael, of Dublin, for " medullary sarcoma," the patient, 
a young woman, dying the next day. There is some 
doubt, however, as to the authenticity of this case. 2 It 
has also been excised once, or perhaps twice, for deformity. 
For the operations performed by J. R. Barton, November 
22, 1826, 3 K. Rodgers in 1830, 4 Maisonneuve in 1847, 5 
and J. C. Warren in 1849, 6 were not excisions of the 
joint, but sections of the shaft of the femur for the estab- 
lishment of a pseudarthrosis. These cases are thus par- 
ticularly referred to, because foreign writers constantly 
allude to them as excisions. 



EXCISION FOR INJURY. 

Instances of excision of the head of the femur for trau- 
matic cause are few in number. The earliest is that re- 
ported by Oppenheim, and performed at the battle of Eski- 
Arna-Utlar, between the Russians and Turks, on the 5th 
of May, 1829, for a gun-shot wound, with fracture of the 
head and neck of the femur and of the upper edge of the 
cotyloid cavity ; the soft parts were little injured, and the 
nerves and large vessels untouched. Everything went on 

1 Am. Journ. of Med. Sc., July, 1852. 

2 South's Chelius, Vol. II. p. 978. Oppenheimer, op. cit, p. 24. Dublin 
Quarterly Journ., Vol. II. p. 436. 

3 N. Am. Med. and Surg. Journ., 1827, p. 292. 
* Am. Journ. of Med. Sc., Feb. 1840. 

5 Arch. Gen. de Med., 4 me serie, Tom. XXV. p. 539. 

6 Boston Med. and Surg. Journ., May 17, 1855. 



EXCISION FOR INJURY. 



93 



well after the excision until the seventeenth day, when, 
" frightened by a case of the plague which entered the hos- 
pital and could not be concealed from him, the patient 
died in twenty-four hours of true typhus." 1 

In Dr. O'Leary's successful case, the only one upon 
record, the patient, whilst on duty in the trenches before 
Sebastopol, on the 19th of August, 1855, had been struck 
over the great trochanter of the left femur by a fragment 
of an exploded shell. A fracture was produced, which 
commenced close to the head of the bone, and extended 
downwards and forwards between the two trochanters, ter- 
minating about an inch and a quarter below the lesser. 
The external wound was small. The head of the femur 
and the trochanters were removed. In twelve weeks the 
man left his bed on crutches. At the end of six months 
he had gradually regained the use of his limb, and, some 
time afterwards, was seen in London, in excellent health. 2 

But ten cases of excision for injury have been reported 
in print, and all of these were for gun-shot wounds. 



Surgeon. 


Result. 


Authority. 


Oppenheim. 


Died on 17th day. 


Gaz. Med., 1835, p. 183. 




Seutin. 


9th " 


Gaz. des Hop., 9 Mars, 1847. 




Schwartz. 


7th " 


Statham's Esraarch, p. 94. 




Crerar. 


" 15th " 


Guthrie's Comment., 5th ed., p 


. 622. 


Hyde. 


« 6th " 


Surg, of the Crimean War, p. 


344. 


Coombe. 


14th " 


Ibid. 




Macleod. 


7th " 


Ibid., p. 338. 




Blenkins. 


Died during 5th week. 


Ibid., p. 341. 




O'Leary. 


Recovered in 6,mos. 


Lancet, July 12, 1856. 




Baum. 


Died in 22 hours. 


Dr. Fock's table, Case No. 37. 





The deaths in the above cases were due in two instances 
to causes not connected with the operation, viz. to the 
plague and to cholera, twice to pyaemia, twice to exhaus- 
tion, and once to gangrene. In two of them no cause is 
assigned. 



i Gaz. Med., 1835, p. 183. 

2 Lancet, July 12, 1856. Guthrie's Commentaries, 5th ed., p. 77. 



94 EXCISION OF THE HIP-JOINT. 

The extent of injury, and the condition of the parts after 
a gun-shot wound of the hip-joint, are as notoriously diffi- 
cult to determine as the cases are certain to terminate 
fatally. Even when the upper part of the femur has been 
shot through, shortening, rotation outwards, and crepitus 
are not always present, and sometimes a very considera- 
ble power of flexion and extension remains. " Picture to 
yourselves,'' says Mr. Guthrie, " a man lying with a small 
hole either before or behind in the thigh, — with no bleed- 
ing, no pain, nothing but an inability to move the limb, to 
stand upon it, — and think that he must inevitably die in a 
few weeks, worn out by the continued pain and suffering 
attendant on the repeated formation of matter burrowing 
in every direction, unless his thigh be amputated at the 
hip-joint, or he be relieved by the operation of excision, 
which, I insist upon it, ought first to be performed." 1 

The chances of recovery after amputation at the hip- 
joint, in military practice, may be inferred from the state- 
ment that the operation was performed by the English 14 
times, and by the French 13 times, in the Crimea, without 
a single recovery ; 2 and in the Schleswig-Holstein cam- 
paign 7 times, with but one successful result. 3 

In such a condition of things, which alternative is to be 
adopted ? By following an expectant course and trusting 
to the resources of nature, an almost invariable mortality 
will ensue. A case occurring at the battle of Solferino, 
diagnosticated as fracture of the neck of the femur, and 
another seen at Nantes in 1830 by M. Boinet, are the only 
recoveries I am aware of which have followed gun-shot 
wounds of the hip-joint. 4 On the other hand, it is as rare 
for amputation to succeed, or for patients to survive more 
than a day or two after its performance, except in civil 
hospital practice. The sole remaining resource, the opera- 

1 Commentaries, (5th ed.,) p. 77. 

2 Macleod, op. cit., pp. 338, 435. 

3 Statham's Esmarch, p. 94. 

4 I/Union Medicale, 28 Juin, 1860. 



EXCISION FOR INJURY. 95 

tion of excision, has at least the advantage of not putting 
life in immediate danger, since one of the patients in the 
cases just recorded lived 5 weeks, others from 6 to 17 days, 
and only one so short a time as 22 hours. 

The operation, therefore, merits further attention from 
the military surgeon, and offers an additional chance of 
saving life in an otherwise almost hopeless class of cases. 
This is the proper aspect of the question ; and the Crimean 
experience, so far as it goes, is conclusive on the point. 
The uselessness of the limb left (if it is useless) is a point 
of minor consideration. 

Upon the general principles already alluded to (p. 5), 
excision ought to be the treatment demanded by that rare 
accident, compound dislocation of the hip-joint. Referring 
to the remarkable case of this kind reported by Dr. W. J. 
Walker of Charlestown, Mass., Dr. Hamilton says : " Had 
the head of the femur been resected before its reduction, I 
cannot doubt but that the unfortunate man's chances of 
recovery would have been greatly improved." 1 

Excision has also been suggested as applicable to another 
class of injuries described by Brodie ; 2 viz. wrenches of the 
hip-joint, where death threatens and usually occurs within 
a week, preceded by a deposit of pus inside the capsule, and 
accompanied by coma and delirium. Mr. Henry Hancock 
once examined the parts after a death taking place in this 
manner. In the joint there was a table-spoonful of fetid 
pus and blood, and a longitudinal rent existed in the cap- 
sule. He remarks that he was strongly impressed with the 
conviction that, if the operation of excision had been per- 
formed, the patient's life might have been saved. 3 

The impossibility of a diagnosis of sufficient accuracy to 
warrant an operation so disastrous as this has proved itself 
to be, must, it seems to me, settle the propriety of its per- 
formance under these circumstances. 

1 Fract. and Disloc, p. 724. 

2 Dis. of Joints, (4th Am. ed.,) p. 74. 

3 Lancet, April 25, 1857. 



96 EXCISION OF THE HIP-JOINT. 



EXCISION FOR DEFORMITY. 

The case previously alluded to as coming under this 
head is that of Anthony White ; it has always passed as 
a successful operation for hip-disease, whereas in reality 
it was for the deformity resulting from an arrested hip- 
disease. It is distinctly stated in the operator's own ac- 
count, 1 that the " formation of fresh abscesses had for some 
months ceased, and further diseased processes were not ap- 
prehended," and that the condition of the boy's health did 
not forbid the operation. The knee of the affected limb 
was immovably fixed on the inner side of the opposite 
thigh, and the examination of the parts removed showed 
very slight, if any, proof of existing disease. The patient 
recovered, and, twelve months afterwards, " enjoyed a most 
useful compensation for the loss of the original joint ; had 
perfect flexion and extension of the thigh and every other 
motion, except that of turning the knee outwards. The 
limb, of course, remained shorter by as much as had been 
cut off from the top of the thigh-bone." 

There seems some probability that the excision performed 
by Mr. Hewson of Dublin, usually stated to have been for 
caries, was also for this cause. The case does not appear 
ever to have been reported, and the various brief references 
to it are as inconsistent as they are numerous. One of the 
most authentic appears to be that of Mr. Carte, who, at a 
meeting of the Dublin Pathological Society, stated that he 
had personal knowledge of the case, and that the operation 
was performed on account of " malposition from an old dis- 
location, with displacement upwards and backwards," the 
patient surviving its performance several months, and then 
dying of profuse suppuration, coexisting with a perforation 
of the cotyloid cavity. 2 

The cure of an anchylosis by means of excision was 

i South's Chelius, Vol. II. p. 979. 
2 Dublin Med. Press, April 28, 1841. 



EXCISION FOR DISEASE. 97 

attempted in 1847 by Maisonneuve of Paris ; but, after 
sawing through the bone, no efforts with chisel or gouge 
could dislodge its head from the acetabulum. The oper- 
ation, therefore, resolved itself into what is called " Bar- 
ton's," and, as such, was successful in straightening the 
limb, previously flexed ; but eighteen months afterwards 
no false-joint had been obtained. 1 A similar experience, 
but followed by a rapidly fatal result, recently occurred 
in an operation for anchylosis, following an injury from 
blasting five months previous, performed by Dr. Peters 
at the New York Hospital. 2 In this case, however, the 
bone was sawed across below the trochanters and through 
the neck, and the segment thus included removed. The 
efforts to extract the head of the bone were unavailing. 

The two instances given, admitting them to have been 
operations for deformity, — of which there is some doubt, — 
hardly warrant generalization as to the propriety of excis- 
ion in similar cases. 



EXCISION FOR DISEASE. 

Setting aside the question of its applicability to malig- 
nant affections of the upper part of the femur, as unworthy 
of consideration, necrosis and " hip-disease " present them- 
selves as the only conditions in which excision is to be 
thought of as a method of remedial treatment. It should, 
however, be said, that the end of the femur has been re- 
moved three times for chronic rheumatic arthritis by Messrs. 
Shaw, Morris, and Fock ; 3 but, as in two of these cases the 
operation would probably not have been undertaken had 

i Arch. Gen. de Med., 4 me se'rie, Tom. XXV. p. 539. Comp. de Chir., Tom. 
II. p. 475. 

2 Am. Med. Times, April 20, 1861. 

3 Lancet, Oct. 18, 1856, and Aug. 14, 1852. Arch, fur Klin. Chir., Band I. 
Heft I. p. 182. 

9 



98 EXCISION OF THE HIP-JOINT. 

the condition of the joint been fully appreciated, it is per- 
haps unnecessary to consider it in relation to this form of 
disease. 

As an instance of the operation for necrosis, and the 
only one I am acquainted with, that performed by the elder 
Textor on the 31st of July, 1884, may be cited. A little 
boy, seven and a half years old, fell on his great trochanter; 
within a few weeks a swelling and abscess formed, and on 
opening this the trochanter and part of the neck of the bone 
were felt to be denuded. The incision already made being 
enlarged, a fracture through the cervix was found, and 
although the bone appeared to be necrosed below the lesser 
trochanter, the saw was applied above that process in order 
to preserve the muscular attachments. Suppuration, bed- 
sores, and gangrene ensued, and the patient died on the 
twenty-third day after the operation. 1 

As a matter of curiosity, the case of Mr. Brandish is 
perhaps deserving of further mention in this connection. 
On the 23d of September, 1783, a lad, twelve years old, 
received a charge of shot from a gun, the whole of which 
passed through the upper part of the thigh and came out 
about the middle of the gluteus maximus. The orifice of 
entrance was about the size of a shilling-piece, that of exit 
somewhat larger. The surgeon " contented himself with 
injecting spirit of turpentine and linseed-oil, warm, into 
the wound by means of a syringe, and afterwards covering 
the wounds with a large poultice of bread and milk." In 
the course of his attendance several exfoliations of bone 
came away, one, in particular, which appeared to be a 
considerable portion of the head of the femur with a shot 
sticking in it. October 5th, 1785, the boy walked toler- 
ably well with the assistance of a crutch. 2 

From two cases such as these, conclusions are not to 
be drawn, and in similar instances general principles must 
prevail as to the course to be pursued. 

1 Gaz. des Hop., Mar. 9, 1847. 2 Lond. Med. Journ., Vol. VII. p. 138. 



EXCISION FOR DISEASE. 99 

The diagnosis of the existence, or of the precise condi- 
tion, of hip-disease, (only a little less frequent, according 
to the statistics of Guy's Hospital, than disease of the 
knee, 1 ) is often obscure and difficult. The advanced 
stages of lumbar abscess, caries of the os iimominatum, 
and of the great trochanter and neck of the femur, have 
been mistaken for it ; and the shortening of absorption, the 
distortion of the pelvis, and the carrying of the limb across 
its fellow, have also been mistaken for the symptoms of a 
spontaneous dislocation, which did not exist. Mr. Fer- 
gusson, of London, after commencing an operation upon 
a young girl of nineteen, — who for sixteen years had suf- 
fered from hip-disease, — with the intention of removing 
the head of the femur, supposed to be carious as well as 
dislocated, found it in its place, firmly attached to the coty- 
loid cavity by anchylosis ; the succession of large abscesses 
about the hip and upper part of the thigh, which had in- 
duced him to operate, depending upon a disease of the 
trochanter major. 2 

The difficulty in diagnosticating the precise condition 
of the parts is also well shown by three cases alluded to 
in the Medical Times and Gazette for September 1, 1858. 
In one, on exposing the joint, the bone rotated in its socket 
without perceptible grating, and the finger discovered no 
carious surface. At length, an opening in the capsular 
ligament was detected ; on enlarging this and turning out 
the head of the bone, it was found to be wholly denuded 
of cartilage, but so protected by soft granulations that no 

1 Bryant, Dis. and Inj. of Joints (Lond. 1859). 

2 Lancet, April 15, 1848, p. 415. 

The application of surgical treatment to caries of the trochanter major 
appears to be followed by very fair success, whenever portions of it or of the 
cervix femoris are removed without opening the capsular ligament. Of ten 
operations of the kind performed by Tenon (Champion, Tr. de la Resect., etc., 
p. 65), Liston (Med. Times, June 18, 1851, p. 689), Fergusson (Lancet, April 
15, 1848), Erichsen (Med. Times and Gaz., March 17, 1860), J. F. Heyfelder 
(Ueber die Resection, u. s. w., p. 160), Textor, d. s. (O. Heyfelder, Operations- 
lehre, u. s. w., p. 92), Parker (Gross. Syst. of Surg., Vol. II. p. 1101), and 
Velpeau (Gaz. Med., No. 3, 1837), eight resulted in recovery. 



100 EXCISION OF THE HIP-JOINT. 

grating was produced. In the second, much embarrass- 
ment was caused by a similar state of things ; and in the 
third case the surgeon abandoned the operation, fearing 
lest he should open a healthy articulation. 

Another important question, raised in connection with 
excision of the hip-joint, has reference to the condition of 
the acetabulum, and the propriety of operating when this 
is diseased. 

There are those who maintain, that, without waiting for 
healing processes to take place in the cotyloid cavity, and 
however much it may be diseased, the operation of excis- 
ion may still be performed. In the autumn of 1833, 
Heine and Jaeger demonstrated upon the dead subject 
the feasibility of removing the head of the bone and the 
whole acetabulum, without wounding the pelvic fascia or 
the peritoneum. 1 Mr. Henry Hancock has also attempted 
to show, that the pelvic organs can in no way be in- 
jured by manipulations practised on the acetabulum, even 
when perforated by the disease, they being protected by 
the fasciae and soft parts within the pelvis, and lifted 
away from the bone by the collection of pus, which forms 
a sort of chamber between it and the viscera. That such 
was the fact, and that such an operation might be per- 
formed upon the living subject, he undertook to prove by 
sawing out the whole acetabulum. The operation was 
performed on the 6th of December, 1856, and the patient, 
from a condition in which he could not long have sur- 
vived, in fourteen days sat up in bed, the first time for a 
year ; in three weeks dressed himself and sat by the fire ; 
in five weeks went upon crutches ; and in four and a half 
months walked in the Park daily. 2 

On the other hand, it is asserted that no operation is 
justifiable unless the acetabulum is free from disease. 
Mr. Henry Smith stated in 1849, that, of all the opera- 
tions which had been practised in Great Britain up to 

1 Oppenheimer, Ueber die Resect, des Hiiftgelenkes, p. 55. 

2 Lancet, April 25, 1857. 



EXCISION FOR DISEASE. 101 

that period, those only were successful in which, at the 
time of their performance, displacement of the head of the 
femur and its more or less carious condition were found 
to be alone the cause of all the disturbance, although dis- 
ease of the acetabulum had perhaps previously existed. 1 

The general opinion of pathologists is, however, that the 
coexistence of pelvic and femoral caries is almost constant, 
after the disease has fairly developed itself. 

According to Mr. Hancock, 2 in 26 operations the ace- 
tabulum was found diseased 18 times, thus : — 

In 2 cases scarcely a trace of the cavity. 

In 3 cases filled with a fibro-gelatinous mass. 

In 6 cases the gouge was used for caries. 

In 1 case enlarged from absorption. 

In 1 case deprived of its cartilage. 

In 1 case perforated. 

In 1 case partly obliterated. 

In 1 case death 2 yrs. after operation from its perforation. 

In 1 case death 3 mos. after operation from its perforation. 

In the 133 cases which I have collected, the acetabulum, at 
the time of the operation, was more or less diseased in 76 ; 
not diseased in 18 ; whilst in 39 its condition is not stated. 

The only cases in which the surgeon can hope to find the 
acetabulum in a healthy condition are those where the 
head of the femur is so much absorbed as not to lie in 
contact with it, or when spontaneous dislocation has for 
some time existed. Even in these, as will presently appear, 
a healthy acetabulum is of infrequent occurrence. 

But it may be said that before either of these results 
can have taken place, the patient will die, worn out^by 
hectic, suppuration, and exhaustion. Is the operation with 
its benefits, if any, to be rejected on this account ? If the 
pelvic portion of the disease sometimes seems to recover 
when the head of the femur is absorbed or dislocated, why 
not give it an opportunity to do this by an operation ? 

Without entering into a discussion as to whether spon- 

1 Lancet, March 17, 1849. 2 Ibid., April 18 and 25, 1857. 

9* 



102 EXCISION OF THE HIP- JOINT. 

taneous dislocation ever does occur, 1 or falling back upon 
Mr. Syme's assertion, that caries, once established, never 
takes on reparative action, 2 the answer to such an argu- 
ment is, that the continuous progress of the disease from 
bad to worse is not the only direction in which it tends. 
Other treatment than excision is not without avail. Mr. 
Smith's cases show that the acetabulum takes on reparative 
action with a considerable degree of readiness ; a limit to 
the destructive processes may be set up by successful ef- 
forts at new ossific production, with gradual cessation of 
the discharge, the healing of fistulse, and final anchylosis. 
Preservative surgery may thus take the place of the more 
heroic conservative methods. The results of the former 
are as likely to be serviceable as those of the latter, and the 
chance of success which it offers is as great as that of an 
operation of which one of the contingencies is, that it may 
destroy life immediately. Half the irritation of the disease 
may be arrested at once by an apparatus for extension, - — 
a method of treatment, the principles of which are sus- 
tained by those on which the practice of excision is based. 
Mr. Holmes Coote says, — and that too after the satisfac- 
tory experience of a successful case of excision under his 
own care, — that he should try extension, " not for weeks, 
nor even for months, but for years, before resorting again to 
so serious an operation as resection of the hip-joint, which, 
however successful in its issue, leaves the patient in a crippled 
state for at least an equal period of time, and which like- 
wise shows, in a large proportion of cases, a fatal result." 3 
In those grave cases where it might be urged that an 
operation affords the only chance of saving life, it must be 
remembered that it is not the articular symptoms which 
usually cause death, but rather the exhaustion produced, 
not by resistance to an incurable local disease, but by the 
general constitutional state, of which the local condition 
and the exhaustion are both only the symptoms ; and to 
whatever extent the local trouble may "aggravate the gen- 

1 Trans, of the Am. Med. Assoc, Vol. VI. p. 479. 

2 Lancet, May 5 and June 9, 1849. 3 Brit. Med. Journ., July, 1858. 



EXCISION FOR DISEASE. 103 

eral symptoms, as it is not the cause of those symptoms, 
so neither will its removal prove the remedy. 

Having thus reviewed some of the most important fea- 
tures of hip-disease as they bear upon the question of opera- 
tive interference, before passing to the consideration of col- 
lected cases and the conclusions to be derived from them, 
it may not be uninteresting to note the results which have 
been arrived at by other writers on this subject. 

In 1848, according to a paper read by Mr. Henry Smith, 
before the Medical Society of London, only 16 cases of ex- 
cision of the head of the femur had at that time been pub- 
lished ; in these there were 8 deaths and 8 recoveries. 1 

In 1849, Santesson, of Stockholm, published a table of 
20 cases, 10 of which were successful, and 10 fatal. 2 

In 1857, Mr. Henry Hancock stated that, of 26 operations 
performed in England, 6 proved fatal within three months ; 
in 3 cases, one patient lived two years, another six months, 
and the third four months ; in 2 cases, the result was not 
known ; in 15 there was a perfect cure. 3 In the same year 
Mr. Erichsen says, that, so far as he can learn, the head of 
the femur has been excised 38 times, with 14 fatal results ; 4 
and Mr. Fergusson expressed his opinion of the operation 
in these words ^" I have now no hesitation in stating my 
opinion, that in properly selected cases the operation will 
prove eminently successful in saving life." 5 

In February, 1860, Mr. Price read a paper before the 
London Medical Society, giving an analysis of 59 cases, 33 
of which had proved "quite successful," and 11 partially 
so ; i. e. the patients had been benefited, both locally 
and constitutionally, living for periods varying from three 
months to two years, death occurring more from other 
causes than from a recurrence of the disease which de- 
manded the operation. The operation was, more or less 
directly, the cause of death in 14 cases. In one case the 
ultimate result was not known. 6 

i Lancet, April 15, 1848. 2 Dublin Quarterly Journ., Vol. XI. p. 432. 

3 Lancet, April 18, 1857. 4 Sc. and Art. of Surg., 2d ed., p. 680. 

5 Pract. Surg., 4th ed., p. 467. 6 Med. Times and Gaz., Feb. 25, 1860. 



104 EXCISION OF THE HIP-JOINT. 

In June, 1860, Dr. Lewis A. Sayre, of New York, pre- 
sented a report on Hip-disease to the American Medical 
Association, connected with which was a table of 110 ex- 
cisions, of which 36 were reported as terminating fatally, 2 
unfavorably, and 72 in recovery, with a more or less use- 
ful joint. 1 

The first number of the Archiv fur Klinische Chirurgie, 2 
contains a table by Dr. C. Fock, of Magdeburg, comprising 
79 excisions for disease, in 36 of which there was a fatal 
result ; 40 were completely or almost cured, and 14 were 
uncertain as to their issue. In 32 of the 40 recoveries, the 
use of the limb was completely regained ; in 9, imperfectly 
regained ; and in 9, " the observations were published at a 
time when nothing could be affirmed as to the result." In 
35 cases where the acetabulum was gouged, there were 17 
recoveries, 11 deaths, and 7 doubtful results. In 32 cases 
where spontaneous dislocation had occurred, there were 16 
recoveries, 9 deaths, and 7 doubtful results. 

Mr. R. Barwell gives 92 excisions for disease, with 56 
recoveries, 32 deaths, and 4 uncertain results. In 36 of 
the above recoveries, the limb was reported as useful ; in 
6, as useless ; whilst in 14 no reliable information could be 
obtained beyond the fact of recovery. 3 

i Trans, of Am. Med. Assoc, Vol. XIII. p. 469. 

A certain amount of reserve is necessary in receiving the results of this 
table, as some inaccuracies have unfortunately crept into its compilation. Thus, 
Case 11 is an instance of "Barton's operation"; Nos. 1, 41, 69, of removal of 
the spontaneously separated head of the femur; and Nos. 4, 23, 57, 97, are 
operations for necrosis or rheumatic arthritis, and not for hip-disease ; whilst 
Nos. 9 and 18, 15 and 16, 52 and 65, 60 and 89, are repetitions of each other. 
Sixteen cas^, viz. Nos. 36, 37, 45, 49, 58, 60, 61, 66, 68, 75, 76, 84, 101, 104, 
105, and 106, not having reached a definite result, — seven of them having been 
under treatment less than six weeks, and none more than three months, — can 
hardly with fairness be considered recoveries. And the want of reference to 
authority for numerous cases, especially Nos. 25, 50, 51, 90 (that given not 
being correct), and 93, is certainly an omission in a table otherwise so com- 
plete in this respect. It is to be regretted that Dr. Sayre has not furnished 
his excellent article with a more elaborate analysis of the cases which accom- 
pany it. 

2 Herausgegeben von Dr. B. Langenbeck, Berlin, 1860. 

3 Treatise on Diseases of the Joints, (London, 1861,) p. 438. 



EXCISION FOR DISEASE. 



105 



It seems proper to make a distinction between those 
cases where the head of the bone, already spontaneously 
separated, is removed, and those in which the separation is 
effected at the time of the operation. The former resem- 
ble operations for necrosis, and admit of less doubt as to the 
propriety of the course pursued. 

From a variety of sources, 21 instances of removal of the 
head of the femur, spontaneously separated from the rest of 
the bone, have been collected. 



Surgeon. 


Result. 


Authority. 


Klinger. • 


Recovered. 


Arch, fur Klin. Chir., Bd. I. s. 213. 


Schlichting. 


" 6 weeks. 


Philos. Trans., Vol. XLII. p. 284. 


Shaw. 


n 


Dublin Quarterly, Vol. XV, p. 290. 


Schmalz. 


" 3 years. 


Oppenheimer, p. 21. 


Batchelder. 


tt 


Am. Med. Month., Apr.1859, p. 379. 


Batchelder. 


" 


N. Y. Med. & S. Rep., Jan. 10, 1846. 


Carlisle. 


tt 


Dublin Quarterly, Vol. XV. p. 290. 


Vogel. 


" 3 mos. 


Sedillot, Med. Op.,T. I. p. 51 1, 2d ed. 


March. 


" 


Am. Med. Times, July 14, 1860. 


March. 


tt 


Ibid. 


Huntington. 


tt 


Catal. of Warren Mus., No. 1147. 


Bowman. 


" 1\ mos. 


Med. Times and Gaz., Sept. 1, 1860. 


Ried. 


Died in a year. Blight's dis. 


Arch. Gen. de Med., [5.] T. II. p.720. 


Simon. 


Died in a few days. Phthisis. 


Lancet, Oct. 17, 1857. 


Harris. 


Recovered in 2 years. 


Philad. Med. Ex., Vol. II. p. 38. 


Kirkland. 


Recovered. 


Arch, fur Klin. Chir., Bd. I. s. 212. 


Hofmann. 


" 


Ibid. 


Schubert. 


u 


Ibid., s. 213. 


Ohle. 


Died soon after of hectic. 


Ibid., s. 212. 


Ross. 


Died in 3 days. 2d'y Hem. 


Ibid., s. 214. 


Kuhn. 


Died in 6 days. Bright's dis. 


Ibid., s. 218. 



These cases hardly require further comment than that 
with which they have been introduced. The separation of 
the bone is itself an effort on the part of nature in a 
curative direction ; and the considerable success — which 
might perhaps be anticipated — attending its removal is 
sufficiently well shown in the above table, exhibiting, as it 
does, but five fatal cases, one of those having occurred after 
the lapse of a year from the date of the operation. 

The table which follows contains the memoranda of 133 
cases of excision of the head of the femur, and, in a certain 
number, of more or less of the acetabulum, for hip-disease. 



106 



EXCISION OF THE HIP-JOINT. 



No. 



Authority. 



1 Oppenheimer, ueber die Resection., 

etc., p. 45. 

2 Ibid., op. cit., p. 41. 

3 Med. Chir. Trans., Vol. 28, p. 576, 

and Med. Chir. Rev., July, 1846. 

4 Med. Chir. Trans, p. 571. 

5 Med. Gaz., Dec. 1849, and July, 1850, 

6 Fergusson's Pr. Surg., 4th ed., p. 465 

and Lancet, Aug. 14, 1852. 

7 Gaz. des Hop., Mar. 7, 1847. 

8 Lancet, Aug. 14, 1852. 

9 Ibid. 

10 Ibid., Apr. 15, 1848. 

11 Ibid., Nov. 25, and Dec. 9, 1848. 

12 Lancet, Jan. 22, and Apr. 7, 1849. 

13 Med. Times and Gaz., Nov. 13, 1852. 

14 Lancet, Feb. 28-, 1852. 

15 Ibid., Jan. 21, 1854. 

16 Brit. Med. Journ., Jan. 2, 1858, Med. 

Times and Gaz., Feb. 20, 1858, and 
Lancet, Apr. 13, 1861. 

17 Records Bost. Soc. for Med. Imp., 

Vol. I. p. 226. 

18 Glasgow Med. Journ., Vol. I. p. 10. 

19 Lancet, Jan. 30, 1858. 



20 Ibid., Mar. 20, 1858, and Nov. 26, 
| 1859. 

21 Med. Times and Gaz., Mar. 28, 1857. 

i 

22 : Ibid., Apr. 21, 1860. 

23 Mass. Gen. Hosp. Records. 

24 j Lancet, May 5, 1860. 

25 J. F. Heyfelder, Ueber Resect, und 
Amp., p. 155. 



Sex. 


Age. 


M. 


54 


M. 


18 


M. 


Ad'lt. 


M. 


14 


F. 


12 


M. 


8 


M. 


15 


M. 


17 


M. 


12 


M. 


33 


F. 


10 


F. 


32 


F. 


8 


M. 


8 


M. 


16 


M. 


11 


M. 


41 


F. 


26 


M. 


H 


F. 


26 


M. 


10 


M. 


9 


M. 


11 


M. 


20 



Result. 



Died. 



Recovered 
Died. 
Recovered 
Died. 



Recovered 

« 

Died. 

Recovered 
« 

Died. 



Recovered. 



Died. 



Amp. Died 



Duration of 
Treatment. 



53 days. 

4 days. 

A few days. 
7 mos. 

6 mos. 

5 mos. 

7 days. 
3 mos. 

A few hours. 
4' days. 
5 mos. 
1\ mos. 

8 mos. 

3 days. 
18 mos. 

4 mos. 

10 days. 

4 mos. 
8 days. 

6^- mos. 
34 mos. 

3 mos. 
16 days. 
20 days. 
12 mos. 



EXCISION FOR DISEASE. 



107 



Condition of Parts and Extent of Excision. 



Bone not disloc. Acetab. healthy. Cut 
off 2 in. below trochanters. R. hip 

Bone disloc. Acetab. cauterized. Head 
alone removed. Left hip. 

Bone not dislocated. 

Bone disloc. Acetab. not touched ; 4|- 

in. removed. Left hip. 
Bone disloc. Acetab. not diseased. Cut 

off below trochanters. Right hip. 
Bone disloc. Acetab. not diseased. 

Head and neck removed. 
Bone disloc. Acetab. not diseased 

Head and neck removed. Left hip. 
Head of bone absorbed. Acetab. 

gouged. Cut off below trochanters. 
Bone not disloc. Acetab. diseased 

Head and neck removed. 
Bone disloc. Acetab. gouged. Head 

and neck removed. 
Bone disloc. Acetab. gouged. Cut off 

below trochanters. Left hip. 
Bone disloc. Acetab. not diseased. Cut 

off below trochanters. Left hip. 
Bone disloc. Acetab. not diseased. Cut 

off below trochanters. Left hip. 
Bone disloc. Acetab. gouged. Cut off 

below trochanters. 
Bone disloc. State of acetab. not men- 
tioned. 
Bone disloc. Acetab. healthy. Head 

and trochs. removed. Right hip. 

Bone disloc. Acetab. diseased, but not 

gouged. Head and neck removed 

Left hip. 
Bone disloc. Acetab. gouged. Head 

and neck removed. Right hip. 
Bone not disloc. Acetab. gouged. Cut 

off below trochanters Portion of 

ischium excised. Right hip. 
Bone not disloc. Acetab. gouged. Cut 

below trochanters. Left hip. 
Bone not disloc. Acetab. gouged. Cut 

off below trochanters. Left hip. 
Bone disloc. Acetab. gouged. Head 

alone removed. Left hip. 
Bone disloc. Acetab. not diseased 

Head and neck removed. Left hip. 
Bone not disloc. Head alone removed 

Right hip. 
Partial disloc. Acetab. gouged. Actual 

cautery applied. Head and neck re 

moved. Left hip. 



Remarks. 



Death from bed-sores. 

Death from diarrhoea. 

Death from the operation. 

Eventually able "to walk 20 miles in a 

day. 
Death from double psoas abscess. 

About on crutches; wound unhealed 
Died 2 yrs. after op. of dis. of liver, 
Death from secondary hemorrhage. 

Sat up in bed in 2 mos. Died in 3 

mos. of general disease. 
Death from hemorrhage. Profunda 

vein opened by an abscess. 
Almost dead when operated on. Pa 

tient was a child. 
Death from great local and general 

disease. Lumbar vertebra? carious 
" Wonderful amount of motion re 

stored." 
Walks with a cane. Died a year or 

two after op. of visceral disease. 
Death from hemorrhage. 

About on crutches, but parts not 
cicatrized. 

Considered by the operator at first to 
be a very successful case. Subse- 
quently, limb as useless as before op. 

Death from exhaustion. 



Death from general disease and diar- 
rhoea. 
Death from erysipelas. 



Bears entire weight of body. Plays 

with other boys. 
Eventually walked with a cane. 

Death from exhaustion and suppura- 
tion. 
Death from exhaustion. 

Death from exhaustion. 

Got about on crutches ; at end of a 
a year caries returned ; at end of 
3% years, amputation, and removal 
of 2\ inches of horizontal ramus of 
pubes. Death 2 hours after opera- 
tion, from the shock. 



108 



EXCISION OF THE HIP-JOINT. 



No. 


Authority. 


Sex. 
M. 


Age. 
12 


Result. 


Duration of 
Treatment. 


26 


Mass. Gen. Hosp. Kecords. 


Died. 


10 mos. 


27 

28 
29 


Med. Times & Gaz., Aug. 8, 1857, and 
Lancet, Oct. 24, 1857, and May 5, 
1860. 

Lancet, Oct. 3, 1857, and Med. Times 
and Gaz., Oct. 24, 1857. 

Lancet, July 31, 1858. 


M. 

M. 
M. 


5 

11 
54 


Recovered. 

« 
Died. 


10 mos. 

5| mos. 

11 days. 


30 
31 


Med. Times and Gaz., Dec. 24, 1853, 
Sept. 23/54, and Lancet, Jan. 21, '54. 

Lancet, Apr. 25, 1857, and Barwell 
on Dis. Joints, p. 445. 


M. 
M. 


14 
14 


Recovered. 


6 mos. 
4£ mos. 


32 
33 


Lancet, Apr. 15, 1848, Fergusson's 
Pr. Surg., 4th ed., p. 467, and Bar- 
well on Dis. Joints, p. 449. 

Charleston Med. Journ., May, 1857. 


F. 
M. 


10 
20 


Died. 


30 hours. 


34 

35 
36 


New York Journ. of Med., Jan. 1855, 
and Am. Med. Monthly, Apr. 1860. 
Private letter. 
Ibid. 


F. 

M. 
M. 


9 

18 
8 


Recovered. 

Died. 
Recovered. 


8 mos. 

13 days. 
5 mos. 


37 

38 


Lancet, May 5, 1860, and Medical 

Times and Gaz., Apr. 7, 1860. 
Lancet, Oct. 17, 1857. 


M. 
M. 


12 

10 


Died. 
it 


39 days. 
10 weeks. 


39 


Schillbach, Resect, der Knoch., p. 12. 


M. 


11 


Recovered. 


13 mos. 


40 
41 
42 


Med. Times and Gaz., Apr. 21, 1860. 

Ibid. 

Lancet, Oct. 17, 1857. 


M. 
M. 
M. 


12 

17 
13 


tt 
it 

Died. 


4 mos. 
12 mos. 

5 weeks. 


43 

44 
45 


Ibid., Oct. 24, 1857. 

Med. Times and Gaz., May 8, 1858. 

Lancet, Oct. 10, 1857. 


M. 
F. 
M. 


37 
23 


it 
« 

Recovered. 


26 days. 
4 days. 
6 mos. 


46 

47 
48 


Ibid., and Apr. 28, 1860, and Med. 

Times and Gaz., Oct. 24, 1857. 
Lancet, July 25 and Oct. 10, 1857, and 

Med. Times and Gaz., Oct.17, 1857. 
Lancet, Jan. 26, 1861. 


F. 
M. 
M. 


5 

7 
4 


Died. 
Recovered. 

u 


3 mos. 
3 mos. 

7 weeks. 


49 
50 

51 
52 


Ibid., Nov. 26, 1859. 

Lancet, Feb. 14, 1852, and Med. 

Times and Gaz., July 2, 1853. 
Lancet, Apr. 15, 1848. 
Glasgow Med. Journ., 1857. 


F. 
F. 

M. 


20 
10 

8 


tt 

Amputat. 


2 years. 
17 mos. 

4 mos. 


53 
54 


Ibid., July, 1857, and Med. Times 

and Gaz., June 5, 1858. 
Beaney, Conserv. Surg., p. 7. 


M. 
F. 


10 
12 


Recovered. 


7 mos. 
1 year. 



EXCISION FOR DISEASE. 



109 



Condition of Parts and Extent of Excision. 



Remarks. 



Bone not disloc. Acetab. carious but 
not touched. Head and neck re- 
moved. Right hip. 

Bone disloc. Acetab. gouged. Head 
and neck removed. Great trochanter 
gouged. Right hip. 

Bone not disloc. Acetab. gouged. 
Head alone removed. Left hip. 

Bone disloc. and absorbed. Acetab. not 
diseased. Cut off below trochanters. 
Right hip. 

Bone disloc. Acetab. gouged. Cut off 
below trochanters. Right hip. 

Bone not disloc. Whole acetab. ex- 
cised with saw. Cut off below tro 
chanters. Right hip. 

Bone disloc. Acetab. not diseased. Cut 
off below trochanters. Right hip. 

Bone not disloc. Acetab. gouged 

Head and neck removed. Right hip 
Bone disloc. Acetab. gouged. Head 

and neck removed. Left hip. 
Acetab. diseased, but not gouged. 
Bone not disloc. Acetab. gouged 

Head and neck removed. 
Bone not disloc. Acetab. gouged. Cut 

off below trochanters. 
Bone disloc. Acetab. gouged. Cut off 

below trochanters. Left hip. 
Bone partially disloc. Acetab. gouged. 

Head removed. Trochanter gouged. 

Right hip. 
Acetab. gouged. Cut off below troch'rs. 
Head of femur alone removed. Left hip. 
Bone disloc. Acetab. gouged. Cut off 

below trochanters. 
Head and neck of bone scraped. 
Acetab. gouged. Head alone removed. 
Bone disloc. Acetab. gouged. Cut off 

through the trochanters. Left hip. ; 
Head of bone absorbed. Acetab. scraped. 

Cut off below trochanters. Right hip. 
Bone not disloc. Acetab. gouged. Head 

and neck removed. 
Acetab. diseased. Cut off through the 

trochanters. Left hip. 
No details of operation. 
Bone not disloc. Acetab. diseased. 

Head and neck removed. Left hip. 
" All above lesser trochanter." 
Head alone removed. 

Acetab. diseased. 



Died from cough and diarrhoea, and 
extensive local disease. 

Walks well with aid of stick. 



Walks without crutches. 
Death from bed-sores. 

Died, worn out by suppuration. 

Walks well with a crutch. At the 
end of 7 mos. phthisis, and death a 
year after. 

Foot ulcerated from imperfect nutri- 
tion. Can bear but a few pounds 
weight on the limb. 

Death from shock of operation. 

7 years after op. jumps rope ; motions 

of joint perfect. 
Death apparently from pyagmia. 
Walks and runs with a cane. 

Death from diarrhoea. 

Death from phthisis. 

Walks tolerably with a cane. 



Walks fairly with a high -heeled shoe. 
A good recovery. 
Death from phthisis. 

Death from suppuration. 

Death from exhaustion. 

Wears a leather cap over hip. Walks 

fairly with a high-heeled shoe. 
Death from valvular disease of the 

heart. 
In 3 mos. bears his weight and walks 

round his bed. 
No details beyond "discharged cured." 

In 2 years a most serviceable limb. 
No details as to exact subsequent 

condition. 
" Walks and bears his weight." 
Not doing well. At end of 4 mos. 

limb was amputated. Recovered. 
No details as to after-condition. 



Bone not disloc. Acetab. healthy. Head Walks well with a high-heeled shoe, 
and 2 in. of shaft removed. Left hip.' 

10 



110 



EXCISION OF THE HIP-JOINT. 



No. 


Authority. 


Sex. 


Age. 


Result. 


Duration of 
Treatment. 


55 

56 

57 


Liverpool Med. Chir. Journ., July, 

1858, p. 252. 
Am. Med. Times, Sept. 1, 1860, and 

Tr. of Am. Med. Assoc., Vol. XIII. 

p. 530. 
Am. Med. Times, Sept. 8, 1860. 


M. 
M. 

M. 


13 
11 

7 


Died. 
u 

Kecovered. 


6 weeks. 
8 days. 

7 mos. 


58 


Ibid. 


M. 


17 


Died. 


4 mos. 


59 


Lancet, Sept. 8,1860. 


M. 




Kecovered. 


10 mos. 


60 
61 


Ibid. 

Am. Med. Times, Nov. 10, 1860. 


M. 

M. 


8 


u 

<( 


8 mos. 
5 mos. 


62 
63 


Ibid. 

Lancet, Nov. 24, 1860. 


M. 
M. 


6 
30 


« 

Died. 


4 mos. 
2 mos. 


64 
65 


Arch. f. Klin. Chir., Band I. s. 176, 

179. 
Ibid., s. 179. 


F. 
M. 


9 
14 


Recovered. 
Died. 


6 mos. 
11 weeks. 


66 


Ibid., s. 180. 


M. 


22 


« 


18 days. 


67 


Ibid., s. 185. 


F. 


13 


a 


14 days. 


68 


Lancet, Feb. 2, 1861. 


M. 


H 


Recovered. 


5 mos. 


69 
70 

71 


Ibid., Jan. 26, 1861. 
Zeitschrift der k. k. Gesellschaft der 
Aertze zu Wien, 9 Janner, 1860. 
Ibid. 


M. 
M. 

M. 


21 
19 

21 




10 mos. 
7 mos. 

4 mos. 


72 
73 


Am.Med.Times,Feb.2,1861, andTr. 

of Am. Med. Assoc.,Vol. 13, p. 556. 
Lancet, July, 24, 1858, and Erichsen, 

Sc and Art of Surgery, 3d ed., 

p. 745. 


F. 
F. 


5 
13 


it 
a 


3 mos. 
4^- mos. 


74 


Lancet, Feb. 2, 1861. 


F. 


6 


a 


2% mos. 


75 


Dr. Sayre's Table, No. 42. 


M. 


3£ 


a 




76 

77 


Ibid., No. 103. 
Ibid., No. 78. 


M. 
M. 


13 

27 


a 

Died. 


7 days. 


78 


Ibid., No. 44. 


M. 


4 


a 


18 mos. 


79 


Ibid., No. 53. 


M. 


3 


a 


12 mos. 


80 


Ibid., No. 54. 


F. 


7 


" 


12 mos. 


81 


Ibid., No. 63. 


M. 


6 


« 


4 mos. 


82 
83 


Ibid., No. 77. 

Dr. Fock's Table, No. 40. 


M. 
M. 


8 


Recovered. 

M 


4 mos. 



EXCISION FOR DISEASE. 



Ill 



Condition of Parts and Extent of Excision. 



Remarks. 



Head and neck absorbed. Cut off be- 
low great trochanter. Left hip. 

Head of bone and extensive removal of 
portions of ilium, ischium, and pubes. 

Bone not disloc. Acetab. healthy. Head 

alone removed. Left hip. 
Head of bone absorbed. Acetab. gouged. 

Cut off at trochanters. Left hip. 
Bone not disloc. Acetab. extensively 

gouged. Cut off below trochanters. 

Right hip. 
Bone not disloc. Right hip. 
Bone not disloc. Head and portions of 

acetabulum removed. Right hip. 
Bone not disloc. 
Bone not disloc. Acetab. gouged. Cut 

off below great trochanter. Left hip. 
Bone not disloc. Acetab. gouged. Cut 

off below trochanters. Left hip. 
Bone not disloc. Acetab. gouged. Head 

alone removed. Left hip. 
Bone disloc. Acetab. not gouged. Head 

and neck removed. Right hip. 
Partial disloc. Acetab. cauterized. 

Head and neck removed. Right hip. 
Head absorbed. Acetab. gouged. Cut 

off through trochanters. Right hip. 
Head alone removed. Acetab. healthy. 
Bone disloc. Acetab. not touched. 

Head and neck removed. Left hip. 
Bone disloc. Acetab. gouged. Cut off 

through the trochanters. Right hip. 
Acetab. gouged. Cut off through tro- 
chanters. Left hip. 
Upper end of femur removed, and whole 

acetab. ; rami of pubes and ischium 

with part of tuber ischii and part of 

dorsum ilii. Left hip. 
Apparent disloc. Cut off through the 

trochanters. Acetab. gougeek Left hip. 
Acetab. gouged. Head, neck, and part 

of trochanters removed. 
Four inches of femur removed. 
Portions of ilium, ischium, and pubes 

removed. 
Acetab. gouged. Cut off through the 

trochanters. 
Acetab. gouged. Part of head and neck 

removed. 
Head and neck alone removed. 

Acetab. and surrounding bone gouged. 

Head and neck removed. 
Acetab. gouged. Head removed. 
Acetab. not touched. Cut off through 

trochanters. 



Death from exhaustion. 
Death from exhaustion. 

Walks without crutches. 

Death from exhaustion. 

No details as to exact subsequent 
condition. 

About, out of doors. 
Able to bear his weight. Left hospital 
as requiring no further surgical aid. 
Considered to have a useful limb. 
Death from diarrhoea and exhaustion. 

On her feet most of the day. Uses a 

cane ordinarily ; can go without 
Death from Bright's disease. 

Death from pyaemia. 

Death from phlebitis. 

No details beyond "discharged cured." 

"Walks with a stick. 
Walks without crutches. 

Walks with a cane. 

Walks with a cane. 

Walks with much ease. 



" Discharged cured." 
Has a movable false joint. 
No details. 



Death from " convulsions." Wound 

not healed. 
Death from " diphtheritic croup." 

Death from " ursemic convulsions 
and exhaustion." 

Death from " inanition and progress- 
ive caries." 

" Useful limb." 

Walks without crutches. 



112 



EXCISION OF THE HIP-JOINT. 



No. 
84 


Authority. 


Sex. 


Age. 


Result. 


Duration of 
Treatment. 


Dr. Fock's Table, No. 69. 


F. 


5 


Recovered. 


3 mos. 


85 


Ibid., No. 70. 


F. 


10 


Died. 


11 days. 


86 


Ibid., No. 76. 


M. 


7 


a 


5 mos. 


87 


Ibid., No. 78. 


F. 


8 


Recovered. 




88 


Ibid., No. 79. 


M. 


10 


" 




89 


Ibid., No. 80. 


M. 


16 


« 


4 mos. 


90 


Ibid., No. 81. 


M. 


21 


« 


12 mos. 


91 


Ibid., No. 88. 


M. 


5 


Died. 


8 days. 


92 
93 


Ibid., No. 89. 
Ibid., No. 34. 


M. 

M. 


27 
26 


« 

Recovered. 


16 days. 
9 mos. 


94 


Textor, d. j. Der zweite Fall. u. s. w., 

p. 6. 
Ibid., p. 3. 
Ibid., p. 11. 
Ibid., p. 16. 
Ibid. 
Ibid. 
Med. Times and Gaz., Apr. 27, 1861. 


M. 


7 


u 


8 mos. 


95 
96 
97 

98 

99 

100 


M. 
M. 
M. 
M. 
M. 
M. 


17 
44 

8 
23 
10 

8 


Died. 
« 


6 mos. 
10 days. 
24 days. 

1 month. 
30 days. 

3 mos. 


101 


Ibid., Aug. 24, 1861. 


M. 


13 


Recovered. 


6 mos. 


102 

103 
104 
105 


Arch. f. Path. Anat. u. f. Klin. Med., 

Band XXI. Heft 3, p. 289. 
0. Heyfelder's Table, No. 64. 
Ibid., No. 65. 
Private Letter. 


F. 
M. 


20 


Died. 

Recovered. 
Died. 


4 mos. 


106 


Med. Times and Gaz., Aug. 10, 1861. 






tt 


10 weeks. 


107 


Private Letter. 


F. 


11 


Recovered 


13 mos. 


108 


Ibid. 


F. 


" 6 


<< 


10 mos. 


109 


Ibid. 


M. 


6 


tt 


7 mos. 


110 


Ibid. 


F. 


13 


Died. 


3 mos. 


111 


Ibid. 


M. 


7 


Recovered 


4 mos. 



EXCISION FOR DISEASE. 



113 



Condition of Parts and Extent of Excision. 



Remarks. 



Acetab. gouged. Cut off below tro- 
chanters. Left hip. 

Bone disloc. Acetab. gouged. Cut off 
through trochanters. 

Acetab. gouged. Cut off below tro- 
chanters. Eight hip. 

Acetab. gouged. Cut off below tro- 
chanters. 

Entire acetabulum and upper third of 
femur removed. 

Acetab. gouged. Cut off below tro- 
chanters. Left hip. 

Bone disloc. Cut off below trochanters. 
Right hip. 

Bone disloc. Acetab. not touched. 
Cut off below trochanters. Right hip. 

Head and neck removed. Left hip. 

Bone dislocated. Head and neck re- 
moved. 

Cut off below trochanters. Right hip. 

Cut off below trochanters. 
Right hip. 
Left hip. 

Left hip. 

Acetab. gouged. Head of femur and 

great trochanter removed. 
Acetab. gouged. Head and part of neck 

removed. 
Right hip. 



Acetab. gouged. Head, neck, and part of 
trochanter major removed. Right hip. 

Acetab. gouged. Head of femur re- 
moved. Disease not wholly eradicated. 

Head and neck absorbed. Acetab. 
healthy. l£ in. of shaft removed. 
Right hip. 

No dislocation. Acetab. gouged. Head, 
neck, and great trochanter removed. 
Left hip. 

Acetab. healthy. Head, neck, and lesser 
trochanter removed. Right hip. 

Acetab. healthy. Head and neck re- 
moved. Left hip. 

Bone disloc. Acetab. gouged. Head 
and neck removed. Left hip. 



No details beyond "discharged cured. 

Death from exhaustion. 

Death from cerebral disease. 

Walks without a cane. 

Requires mechanical assistance in 

walking. 
Walks well with crutches. 

Walks with a cane and a high heel. 

Death from pyaemia. 

Death from pycemia. 

Died from phthisis three years after 

operation. 
Earns his living as a travelling tailor, 

Walks with a high heel and a cane. 

Death from psoas abscess. 

Death from phthisis. 

Walks four miles a day with a cane. 



Death from erysipelas. 

Death from bed-sores and erysipelas 

Death from exhaustion. 

Walks with the aid of a splint. 

Walks without assistance. 



Plays about, wearing a splint which 

takes the weight off the limb. 
Death from exhaustion. 

Walks with the aid of a splint, which 
takes the weight off the limb. 



10* 



114 



EXCISION OF THE HIP-JOINT. 



Incompleted 



No. 


Authority. 


Sex. 


Age. 


Time under 
Treatment. 


112 


Med. Times and Gaz., May 5, 1860. 


M. 


11 


6 weeks. 


113 


Lancet, July 24, 1858. 


F. 


10 


2 mos. 


114 


Med. Times and Gaz., Feb. 7, 1857. 


M. 


17 


3 mos. 


115 


Ibid., Nov. 1, 1856. 


F. 


14 


3 mos. 


116 


Ibid., July 22 and Oct. 21, 1854. 


M. 


8 


3 mos. 


117 


Lancet, July 18, 1857. 


M. 


12 


1 month. 


118 


Ibid., Oct. 10, 1857. 


F. 


11 


2 mos. 


119 


Medical Gazette, Aug. 30, 1850. 


F. 


13 


2 weeks. 


120 


Med. Times and Gaz., Sept. 1, 1860. 


M. 


4 


5 weeks. 


121 


Arch. f. Klin. Chir., Band I. s. 184. 


F. 


13 


3 mos. 


122 


Am. Med. Times, Feb. 2, 1861. 


M. 


17 


2 weeks. 


123 


Lancet, April 22, 1854. 


F. 


13 


18 days. 


124 
125 


Am. Med. Times, Aug. 4, 1860, and Trans, of 

Am. Med. Assoc, Vol. XIII. 
Fock's Table, No. 90. 


M. 
M. 


4 
10| 


6 weeks. 
2 mos. 


126 


Med. Times and Gaz., July 17, 1858. 








127 


Sayre's Table, No. 58. 


F. 


9 




128 


Ibid., No. 101. 


F. 


4 


3 mos. 


129 


N. A. Med. Chir. Rev., March, 1858, p. 325. 


F. 


13 


10 days. 


130 


Private Letter. 


F. 


21 


8 mos. 


131 
132 


Am. Med. Times, July 6, 1861, and Private 

Letter. 
San Francisco Med. Journ., July, 1861. 


M. 
F. 


4 
5 


3^ mos. 
5 weeks. 


133 


Private Letter. 


F. 


13 


9 mos. 



EXCISION FOR DISEASE. 



115 



Cases. 



Extent of Excision, &c. 



Present Condition. 



Bone disloc. Acetab. gouged. Head 
and neck removed. 

Bone not disloc. Cut off below trochs. 
Small portion of ilium removed. 

Bone disloc. Acetab. diseased. Head 
and neck removed. 

Bone dislocated. Head and neck re- 
moved. 

Acetab. gouged. Head and neck re- 
moved. Right hip. 

Bone disloc. Acetab. gouged. Cut off 
below trochanters. 

Partial disloc. Almost the whole ace- 
tab. removed. Cut off below tro- 
chanters. Right hip. 

Bone disloc. Head absorbed. Acetab. 
diseased. Cut off below trochanters. 

Partial disloc. Acetab. healthy. Head 
absorbed. Cut off below trochanters. 
Right hip. 

Acetab. gouged. Cut off below tro- 
chanters. Left hip. 

Upper portion of femur. 

Bone disloc. Cut off below trochanters. 

Head absorbed. Acetab. gouged. Cut 

off below trochanters. Left hip. 
Cut off through trochanters. Left hip. 



Head and neck removed. 

Acetab. gouged. Cut off through 
trochanters. 

Bone disloc. Acetab. healthy. Head, 
neck, and 3 in. of shaft removed. 
Left hip. 

Bone not disloc. Cut off below tro- 
chanters. Left hip. 

Acetab. gouged. Head and neck re- 
moved. Right hip. 

Acetab. gouged. Head and part of 
neck removed. 

Acetab. gouged. Head and 3 in. of 
shaft removed. Right hip. 



Doing well. 

Doing well, and sent to Margate. 

Doing well. 

Able to lift the limb, but not yet out 

of bed. 
Sent to Margate. 

Can raise the leg. 

" Prospect of successful issue." 

No details. 

Moves limb of own accord. 

Wound nearly healed. Symptoms 

of phthisis. 
Doing well. 

Doing well. 

" Wound healed, with motion." 

Doing well. 

Doing exceedingly well. 

Promises a useful limb. 

Not yet able to bear any weight. 

Doing well, steadily progressing. 

" Gradually running down." 

Some prospect of recovery. 

About on crutches. 

" Recovery not probable." Sacrum 
carious. 



116 EXCISION OF THE HIP -JOINT. 

In the preceding 133 cases, completed and incompleted, 
89 patients were males, 38 females, and in 6 the sex is 
not stated. 

Of 79 excisions in which the fact is noted, 36 were of 
the right hip and 43 of the left. These numbers hardly 
tend to confirm the observation as to the greater frequency 
of disease on the left side advanced by Mr. Lonsdale, who 
says, that of 112 deformities of the hip from disease, pre- 
sented for treatment at the Royal Orthopedic Hospital, Lon- 
don, 65 were of the left hip and 47 of the right. 1 

Of the 111 completed cases, 5Q resulted in recovery with 
more or less useful limbs, and 53 were fatal, at periods 
after the operation varying from a few hours to eighteen 
months. One patient, at the end of four months, under- 
went amputation, from which he recovered ; another, after 
the lapse of three years and a half, — the disease having 
returned at the end of one year, — also had his limb am- 
putated, and died two hours after the operation. The rate 
of mortality, throwing out the case fatal after amputation, 
appears therefore to be 47.74 per cent. Even adding to 
these 111 the other 22 cases of which the details are given, 
but where no definite result had been reached, and consid- 
ering them all to have terminated in recovery, there would 
still be a mortality of 39.84 per cent. 

Of the patients recovering, 26 were able to walk either 
with a cane or a high-heeled shoe, and 8 by the aid of 
crutches or other support for the limb ; whilst in 22 the 
final condition, beyond the mere fact of recovery, is not 
stated. The disease returned, and a fatal issue resulted, 
in four cases, viz. Nos. 6, 13, 31, 93, at the end of periods 
varying from one to three years. 

The oldest patients were two men, aged 54, both of 
whom died of bed-sores, one in 11 and the other in 53 
days. The youngest patient was a boy 3 years old, who 
died twelve months after the operation, of " diphtheritic 
croup," the condition of the limb at the time not being 

1 Lancet, Sept. 8, 1855. 






EXCISION FOR DISEASE. 117 

reported. The average age of those recovering was ll^f 
years, and of those not recovering 17£f years. 

In the most successful cases the condition of the limb 
appears to have been one of great serviceableness. Mr. 
Fergusson's first patient, eight years after the operation, 
was in excellent health, and could walk twenty miles in a 
day ; his limb was perfectly straight, only slightly everted, 
and had but four and a half inches shortening. The end 
of the femur might be felt, somewhat rounded, playing 
easily upon the ilium ; either limb could be bent upon the 
pelvis with almost equal facility ; there was a very consid- 
erable power of extension and rotation, and also, what has 
been absent in other cases, of abduction. He wore a high- 
heeled boot and walked with a stick. The sound limb was 
a good deal bent, from the knee downwards, to accommo- 
date itself to the deficiency in the other, and there was 
therefore but little limping in progression. 1 A patient of 
Mr. Price's was able to join in many of the sports of his 
companions ; and in several instances false joints were 
obtained, which admitted of very tolerable motion. In 
almost all the cases which did well, a vastly improved con- 
dition of general health ensued, even though, as not unfre- 
quently happened, fistulas remained open, and more or less 
discharge continued. In some, however, recovery means 
only a prolongation of life, with the riddance of an irri- 
tating and profusely suppurating sore, death taking place 
within a year or two, from general disease. 

In the fatal cases, the causes of death were as follows, 
and at the expiration of the time annexed : — 

17 of exhaustion, diarrhoea and suppuration ; in 6, 4, 3, 
3, 2 months ; 10, 6 weeks ; 39, 26, 20, 16, 11, 11, 8, 4, 4, 
4 days. 

8 of general disease and phthisis ; in 10, 5, 4, 4, 3, 3 
mqnths ; 10, 5 weeks. 

4 of pyaemia ; in 18, 16, 13, 8 days. 

3 of hemorrhage ; in 7, 3 days ; " a few hours." 

1 Med. Times and Gaz., Dec. 4, 1852. 



118 EXCISION OF THE HIP- JOINT. 

2 of the operation ; in " a few days " ; 30 hours. 

2 of bed-sores ; in 53, 11 days. 

2 of psoas abscess ; in 6 months ; 24 days. 

4 of erysipelas and phlebitis ; in 4 months ; 14, 8 days ; 
in one the time is not given. 

2 of cerebral disease ; in 18, 5 months. 

1 of valvular disease of the heart ; in 3 months. 

1 of Bright's disease ; in 11 weeks. 

1 of " uraemic convulsions and exhaustion "■; in 1 year. 

1 of " diphtheritic croup " ; in 1 year. 

5 from causes not reported ; in 30, 10, 7 days ; in two 
the time is not given. 

Of these fatal and the two unsuccessful operations, 16 
were of the right, and 14 of the left hip ; in 25, the side is 
not stated. 

To analyze the table of completed cases still further, it 
appears that in 64 in which the acetabulum was diseased, 
the head of the femur is said to have been dislocated in 
20, and not dislocated in 18 ; the head of the bone was 
absorbed in 4, and in 22 cases its position is not reported. 

Of the 20 patients in whom dislocation had taken place, 
12 died, and one underwent amputation, and subsequently 
died. 

Of the 18 where no dislocation had taken place, 7 died. 

Of the 4 cases where the head of the bone was absorbed, 
3 were fatal ; and of the 22, in which its position was not 
stated, 10 were fatal and 12 terminated in recovery. 

Of 16 cases where the acetabulum was not diseased, the 
head of the femur was dislocated in 9, not dislocated in 3, 
and absorbed in one ; in 3 its position is not mentioned. 

Of the first category, 4 were fatal ; of the second, one. 
The case in which the head of the bone was absorbed re- 
sulted in recovery, and of the 3 in which its position is not 
given, one was fatal. 

Stating these facts in a tabular form, they appear as 
follows : — 



EXCISION FOR DISEASE. 



119 



State of the Parts. 


Recoyered. 


Died. 


Acetab. diseased and bone dislocated, 
" " " not dislocated, 

Acetab. not diseased and bone dislocated, 
" " " not dislocated, 
" " and head of bone absorbed, 

Acetab. diseased and head of bone absorbed, 


7 

11 

5 

2 

1 
1 


13 

7 
4 


3 



It seems, then, that the greatest mortality accompanied 
those cases in which the acetabulum was diseased and the 
bone dislocated, and the least mortality those where the 
acetabulum was not diseased and the bone dislocated. 
These facts seem to show, moreover, that dislocation is no 
evidence of a healthy acetabulum. 

Looking simply at the condition of the acetabulum, a 
mortality of 50.15 per cent follows operations when it is 
diseased, and of 37.50 per cent when it is healthy. In 58 
cases in which the acetabulum was gouged, cauterized, or 
scraped, there were 28 recoveries and 30 deaths, — one 
being after a subsequent amputation. This represents a 
mortality of 51.72 per cent. In 50 cases in which the 
acetabulum was not gouged, there were 26 recoveries, 23 
deaths, and in one case the limb was amputated after the 
excision, and the patient recovered. Here the mortality 
is 44 per cent, or 7.72 per cent in favor of non-inter- 
ference. In 3 cases where the acetabulum was diseased, 
but not gouged, the result was fatal. 

As in the shoulder, therefore, the balance is in favor of 
partial excision. This is doubtless due to much the same 
reasons ; but especially, perhaps, to the immobility of the 
pelvis during the processes of cure, as compared with the 
opposing parts of ginglymoid joints, where partial opera- 
tions have been so much condemned. 



120 EXCISION OF THE HIP-JOINT. 



OPERATION AND AFTER-TREATMENT. 

The incisions proper for the performance of excision of 
the head of the femur will depend in a measure upon the 
sinuses which exist, the position into which the limb may 
have become contracted, and upon other circumstances 
which may be peculiar to individual cases. A curved incis- 
ion just above the prominence of the great trochanter, with 
its concavity directed downwards in the long axis of the 
limb, or a straight one in the direction of the femur, of four 
to five inches in length, the centre of which shall fall upon 
that process, are those usually found most convenient. 

The precaution should be taken to separate the head of 
the bone from the acetabulum and its other attachments, 
before dividing it, as otherwise its removal may prove em- 
barrassing, especially if the head and neck alone are to be 
excised. The great trochanter, whether diseased or not, 
should always be removed, as, when left, it is apt to project 
into the wound, prevent healing, and act as a cap to the 
acetabulum, obstructing the discharge of pus and of carious 
portions of the bone. 1 Removal of the shaft of the femur, 
to an extent exceeding two inches, can hardly be consid- 
ered justifiable. Any saw, or even a strong pair of bone- 
forceps, may be used to accomplish the section. 

The gouge is the only instrument applicable to the 
removal of diseased bone from the acetabulum. The ex- 
section, with 'the saw, of the whole acetabulum, and two in- 
stances in which other portions of the os innominatum were 
removed, are operations that cannot but be strongly con- 
demned, even if sanctioned by so eminent a surgeon as Mr. 
Erichsen, who boasts of having, on one occasion, excised, 
with perfect success, " the upper end of the femur, the ace- 
tabulum, the rami of the pubes and of the ischium, a por- 
tion of the tuber ischii, and part of the dorsum ilii." 2 The 

1 Fergusson, Pr. Surg. (4th ed., London,) p. 466. 

2 Sc. and Art. of Surg., (3d ed., London, I860,) p. 745. 



OPERATION AND AFTER-TREATMENT. 121 

same may be said of the application of the actual cautery 
to the carious cotyloid cavity. 

The ligature of any blood-vessels seems seldom to be 
required ; but the occurrence of hemorrhage, sufficient to 
prove fatal, in several of the cases comprised in the table 
just examined, shows how carefully the wound should be 
searched and any oozing stanched ; remembering that a 
very slight loss of blood in an enfeebled, anaemic child 
may turn the scale against recovery. 

The subsequent treatment demands little more than rest 
and the maintenance of the limb in a proper position. A 
great deal of attention is required to keep it in a right 
direction with the body. The tendency in the end of the 
femur to protrude at the wound, is another point to be 
especially remembered. A bottle of water attached to the 
foot will partially control this ; but no regular extension 
is usually required, unless previous dislocation has short- 
ened the limb very much by pushing up the head of the 
femur on the ilium, or when, from long contraction, the 
limb cannot be completely straightened. 

In Mr. O'Leary's successful excision after a gun-shot 
wound, the limb was placed in a sling, made of strong can- 
vas, which hung from a beam over the man's cot, and the 
plane of which formed an angle of 20° with the horizon. 
This method of treatment was adopted in order to promote 
the approximation of the upper end of the bone to the pel- 
vis, as well as to prevent the lodgement of matter amongst 
the tissues, and to favor its escape. 1 

Suggested by and in imitation of the above apparatus, 
there has been used in London, in a number of cases, what 
is called a " hammock swing." This was contrived by 
Mr. Heath of King's College Hospital, and consists of a 
broad sheet of cotton passed under the patient, and perfo- 
rated with holes to permit the evacuation of the bowels, and 
for the dressing and discharge of the wound. The ends of 

1 Med. Times and Gaz., April 4, 1857. 
11 



122 EXCISION OF THE HIP-JOINT. 

the sheet are then attached to what is known in England 
as " Salter's swing," or a high " cradle." The limb is 
thus suspended, as in Mr. O'Leary's case. 1 The apparatus 
seems to have pleased many surgeons who have used it. 
Some complain, however, that the aperture for dressing 
the wound is objectionable, as the soft parts become forced 
into it in such a way as literally to become strangulated, 
like a hernia. 

A very long time must elapse before recovery can be said 
to be established, although cases will vary in this respect. 
Thus one patient will leave the hospital in two and a half 
months, whilst it takes another thirty-four months to reach 
the same condition. The average time spent under treat- 
ment in 49 cases of recovery, where this fact is noted, 
appears to have been 230f§ days. 

Constitutional treatment by chalybeates, tonics, etc., and 
the earliest use of crutches, the sooner to get the patient 
under hygienic influences, are of course the most important 
of all measures which can suggest themselves for the pro- 
motion of rapid recovery. The splints of Drs. Davis and 
Sayre, and especially that of Dr. E. Andrews of Chicago, 
used by its originator with great success, in which the peri- 
neum rests upon a crutch-piece extending down the inner 
side of the limb, and riveted to the heel of the shoe, are, in 
many instances, admirably adapted to take the place of 
crutches after excision of the head of the femur. 

The success of one of the two cases in which amputa- 
tion was performed subsequently to the excision, does not 
justify the course pursued, or encourage a repetition in 
other cases, where the primary operation either is, or 
threatens to become, a failure. 

i Lancet, Oct. 1857, p. 341. 



DISSECTIONS. 123 



DISSECTIONS. 



A limited number of dissections in cases, where recov- 
ery had long been established, have been made, and ex- 
hibit a sufficiently favorable condition of the parts. 

In Anthony White's case (p. 96), the patient died of 
phthisis five years after the operation, and the dissected 
preparation of the parts about the hip-joint is in the mu- 
seum of the Royal College of Surgeons, London. This 
shows the end of the femur largely covered with fibrous 
tissue, and very loosely, though firmly, connected, on the 
inner side, with a mass of the same structure, filling up 
the hind part of the hip-socket. The condition may be 
described as a false anchylosis, with a connecting medium 
long enough to permit of some movement. The anterior 
portion of the acetabulum is filled with new bone. There 
is no appearance of a synovial membrane, capsular liga- 
ment, or other part of a true joint. 1 

In the case operated on by Eied (p. 105), where the 
patient lived a year, pseudarthrosis was established ; two 
rounded processes had shot out from the end of the fe- 
mur, the upper one being united by a very firm, fibrous 
substance to a sort of process, developed just below the 
acetabulum ; whilst the other, situated in front of the 
lesser trochanter, was united in a similar manner to the 
old articular cavity. The movements of the bone were 
limited. 2 

A prepared specimen from a patient of the late Mr. G. 
M. Jones of Jersey (Channel Islands), shows the upper 
end of the thigh-bone resting against the ilium, — just 
above the acetabulum, which is partially obliterated, — 
and bound down to it by a dense and tough fibrous tis- 
sue, forming almost a complete capsular ligament. 3 

1 South's Chelius, Vol II. p. 980. 

2 Arch. Gen. de Med., 5 me Se'rie, Tom. II. p. 720. 

3 Med. Times and Gaz., Nov. 4, 1854. 



124 EXCISION OF THE HIP-JOINT. 

Iii Textor's case (No. 1), where the patient died on the 
fifty-third day, new osseous development had commenced 
on the end of the femur, and the cotyloid cavity was 
filled up with granulations, in which were points of ossific 
deposit. The femur rested upon the posterior edge of the 
acetabulum, and had produced there a depression one and 
a half inches long, an inch wide, and two lines deep. 1 

In a case of Mr. Hancock's, which was dissected twelve 
months after the operation, the end of the femur rested 
against the upper margin of the acetabulum, and was en- 
closed and shut in by a tough capsule, deficient at its 
posterior part. The end of the bone was rounded off, and 
the orifice of the medullary tube was partially closed in 
by a thin plate of bone. It is also said, that " a singular 
adaptation of parts, in order to compensate for the ab- 
sence of the cervix femoris, was found ; namely, a bend- 
ing inwards of the descending ramus of the pubes, and 
of the ascending branch of the ischium." 2 



CONCLUSIONS. 



From what has been stated, it seems not improper to 
conclude, — 

First, That the earliest excision of the head of the 
femur was performed by Anthony White of London, in 
April, 1822 ; and of the whole hip-joint by Mr. Hancock, 
December 6, 1856. 

Second, That, although excision for injury has been per- 
formed but a few times, and with but slight success in sav- 
ing life, the history of the cases is encouraging, presents 
a better record than disarticulation, and therefore, as re- 
placing the latter, deserves further repetition. 

1 Oppenheimer, Ueber die Resection des Hiiftgelenkes, p. 50. 

2 Barwell, Tr. on the D is. of Joints, (Lond., 1861,) p. 447. 



CONCLUSIONS. 125 

Third, That facts are wanting to substantiate the pro- 
priety of excision for deformity, necrosis, or malignant dis- 
ease. 

Fourth, That the removal of the head of the femur, 
spontaneously separated from the rest of the bone in the 
course of disease, is usually unaccompanied by danger, 
and — the general condition of the patient permitting — 
followed by recovery. 

Fifth, That the general results of excision for hip-dis- 
ease are unfavorably modified by disease of the acetabu- 
lum, and by efforts to remove this with the gouge ; but 
that dislocation of the head of the femur does not appear 
to exercise much influence either in favor of, or against, 
operative interference. 

Sixth, That, considering the mortality after the oper- 
ation, — viz. one death in every 2 T 5 ^ cases, — and the suc- 
cess which follows less heroic methods of treatment, ex- 
cision for " hip-disease " does not merit a very favorable 
verdict. 



11 



126 EXCISION OF THE KNEE-JOINT. 



KNEE-JOINT 



HISTORY. 



The first public proposition to excise the knee-joint was 
made in a letter written by Mr. Henry Park of Liverpool, 
to Mr. Percival Pott of London, dated September 18, 1782, 
and published in 1783, entitled, " An Account of a New 
Method of Healing Diseases of the Joints," etc. ; this being 
" total extirpation of the articulation, or the removal of the 
extremities of all the bones which form the joint, with the 
whole, or as much as possible, of the capsular ligament, 
thereby obtaining a cure by callus, or by uniting the femur 
and tibia into one bone without any movable articulation." 

In the spring of 1781, Mr. Park commenced some long 
contemplated experiments upon the dead subject, to ascer- 
tain the best method of performing this operation, and on 
the 2d of July of the same year excised the knee-joint of 
Hector McCaghen, a sailor, aged thirty-three. This patient 
began to walk in July, 1782, and eventually " made several 
voyages to sea, in which he was able to go aloft with con- 
siderable agility, and to perform all the duties of a sea- 
man ; he was twice shipwrecked, and suffered great hard- 
ship, without feeling any further complaint in that limb, 
but was at last unfortunately drowned by the oversetting 
of a flat in the river Mersey." 1 On the 22d of June, 
1789, Park operated, for the second time, on a man named 
Charles Harrison, aged thirty. The case, not being well 
chosen, but unsuited to the operation, both from the con- 
dition of the general health and the extensive implication 
of the soft parts in the disease, terminated fatally, October 
13,1789. 

1 Jeffrey's Park and Moreau, p. 47. 



HISTORY. 127 

The account of this second operation, in a letter to Dr. 
Simmons, dated September 5th, 1789, and which appeared 
in the London Medical Journal (Vol. XI., 1790, p. 282), 
contains an announcement that the publication of his first 
case had elicited a letter from Mr. Filkin of Northwich to 
Mr. Binns of Liverpool, claiming priority in the perform- 
ance of this excision. Unfortunately Mr. Filkin was seized 
with a paralytic affection, which impaired his faculties, and 
at last caused his death, before any details of the case 
could be obtained. His son, however, hunted up the pa- 
tient, who was still living, and communicated the follow- 
ing facts to Mr. Park. The subject of the operation was 
a man of a scrofulous constitution, who had had disease 
of the knee for many years. A fall from a horse frac- 
tured his patella, and nearly half a pint of fetid pus ran 
out by a small wound which opened into the joint. The 
friends refused to have the limb amputated, as was deemed 
necessary, and Mr. Filkin, who had once excised the knee 
on the dead subject, proposed that operation in its stead ; 
this was consented to, and he accordingly performed it, 
August 23, 1762, removing the patella and the ends of the' 
femur and tibia, which were much diseased. November 
21st, the patient had so far recovered that no further at- 
tendance was required. The degree of usefulness result- 
ing can only be inferred from the statement of Mr. Filkin, 
that the man " frequently went to Liverpool," where he 
would ask him to call and see Mr. Park. 

The knee-joint was next excised, September 17th, 1792, 
by the elder Moreau. Just as a successful result was being 
reached, the patient died of epidemic dysentery, three and 
a half months after the operation. 1 In 1809, the operation 
was performed by Mulder of Groningen ; 2 in 1811, by the 
younger Moreau 3 ; and, in 1816, by Roux ; 4 but. not until 

1 Jeffray's Park and Moreau, p. 130. 

2 Wachter, De Artie. Extirp., p. 30. 

3 Diet. des. Sc. Med., Vol. XLVIL, Art. Resection. 

4 Diet, en 30 Vols., Art. Genou. 



128 EXCISION OF THE KNEE-JOINT. 

1823, in which year it was practised in Dublin twice by Sir 
(then Mr.) Philip Crampton, 1 was it repeated in the United 
Kingdom. In 1829, and a second time in 1830, it was per- 
formed by Mr. James Syme of Edinburgh ; 2 as also, in the 
last-named year, by Jaeger of Erlangen ; 3 and subsequently 
by Fricke, Textor, Demme, Heusser, and others. In 1850, 
Mr. Fergusson operated in London ; 4 and since then the 
knee has been excised in Great Britain alone several hun- 
dred times. 

Upon the Continent and in America the operation has 
been infrequently performed, although in the latter coun- 
try, within three or four years, the surgeons of hospitals 
have occasionally undertaken it. Since the excision by 
Roux, in 1816, it has been repeated in France only on 
three occasions ; viz. by Maisonneuve in 1847 , 5 Nelaton in 
1851 -52, 6 and by Follin in 1859. 7 

It was first practised in the United States by Dr. R. A. 
Kinloch of Charleston, S. C, June 24, 1856 ; 4 and I am 
aware of 29 operations having been performed in this coun- 
try since that date. 

Excision of the knee-joint has been performed for injury, 
for deformity, and for disease. 

i Dublin Hosp. Rep., Vol. IV. p. 196. 

2 On the Excision of Joints, p. 135. 

3 Operatio Resectionis Conspectu Chronologico Adumbrata, p. 8. 

4 Lancet, Aug. 10, 1850. 
6 Ibid., Aug. 11, 1849. 

6 O. Heyfelder, op. cit., p. 106. 

' L'Union Medicale, June 21, 1859. 

8 Am. Journ. of Med. Sc, July, 1859. 






EXCISION FOR INJURY. 129 



EXCISION FOR INJURY. 



Upon but few occasions has the knee-joint been excised 
for traumatic cause. Excepting gun-shot wounds, com- 
pound fracture and dislocation, and separation of the epi- 
physis of the lower end of the femur, are the only injuries, 
within my knowledge, which have been treated by excision. 

The gravest symptoms follow the penetration of the 
knee-joint by a gun-shot missile. Macleod says : " I have 
never met with one instance of recovery, in which the 
joint was distinctly opened and the bones forming it much 

injured, unless the limb was removed. # I have 

conversed with many persons of large experience on the 
subject, but never heard of any case recovering, without 
amputation, in which the diagnosis of fracture of the epi- 
physis was without a doubt. In December, 1854, 

I saw upwards of forty cases in the French hospitals, and 
all died except those primarily amputated." 1 Esmarch 
says : " All gun-shot injuries of the knee-joint, in which 
the epiphysis of the femur or tibia has been affected, de- 
mand immediate amputation of the thigh." 2 These opin- 
ions are equally those of other military surgeons. 

But whether excision may be adopted with any propri- 
ety as a substitute for amputation in the class of injuries 
above described, statistics, unfortunately, do not enable us 
to decide. Only six instances are known in which it has 
been practised. One, of complete excision, and a second- 
ary operation, performed in the Crimea, proved fatal after 
twenty-eight days, from exhaustion and diarrhoea. 3 The 
second occurred in the Indian campaign of 1857-58, 
where a native soldier underwent amputation of the left 
thigh and excision of the right knee, immediately after 

1 Surgery of the Crimean War, pp. 310, 315. 

2 Statham's Stromeyer and Esmarch, p. 96. 

3 Med. and Surg. Hist, of the Brit. Army which served in Turkey and the 
Crimea, (Lond. 1858,) Vol. II. p. 379. 



130 EXCISION OF THE KNEE-JOINT. 

an injury in the affair of Alumbaugh. He died the next 
evening with symptoms of shock. 1 The third case, a 
partial excision, the end of the femur alone being re- 
moved, was performed by Dr. Fahle, during the Schles- 
wig-Holstein campaign, three days after the injury, and 
terminated fatally a month after the operation, from tu- 
bercular disease, with pyaemic deposits in the lungs and 
elsewhere. On examination, the cartilage of the tibia was 
found partially thrown off, and a portion of it was still 
attached to the bone. 2 The ulceration and discharge 
necessary for the separation of so extensive a cartilagi- 
nous surface might have been avoided, and the chances 
of recovery perhaps improved, by its removal at the time 
of the operation. Two cases operated on in 1847 and 
1852 by the Textors, father and son, may be cited as 
additional illustrations of partial excision ; one of them 
was for a gun-shot injury of which we have no details, 
and the other for compound fracture, with separation of 
the ligamentum patellae, and both terminated fatally, from 
pyaemia, within a few days. 3 

Besides the above instances, the two following, occur- 
ring in civil practice, are to be included in the present 
category. 

A man twenty years of age received, at a distance of 
twelve feet, a charge of No. 6 shot, loaded with a paste- 
board wad. It entered above the right knee, and passed 
through the condyles of the femur into the inner side of 
the left knee, where the shot penetrated just beneath the 
skin. The veins, nerves, and arteries of the right leg 
were not injured. Complete excision of the joint to the 
extent of three inches was performed, and one inch of 
the integument was also removed. The patient died of 
tetanus fifty-two hours after its first symptoms appeared, 
and ten days after the operation. 4 

1 Edinb. Med. and Surg. Journ., Oct. 1860. 

2 Statham's Stromeyer and Esmarch, p. 99. 

3 0. Heyfelder, op. cit., p. 127. 
* Lancet, April 20, 1861. 



EXCISION FOR INJURY. 131 

A lad, aged nineteen, received a charge of shot in the 
inner condyle of the left femur, penetrating but not per- 
forating the bone. A slice was excised from each bone 
so as to furnish a surface for anchylosis, and then the 
condyle containing the shot was removed by an oblique 
cut. The patella was left. At the end of three months 
the patient walked easily with the aid of a stick, and the 
patella remained loose and movable. 1 

Of these six cases, therefore, but a single one terminated 
favorably. 

For other traumatic causes, the following examples of 
excision may be cited. 

1. A young man fell with his knee on the cutting edge 
of a scythe. The wound was such that there seemed no 
other resource than amputation. The patient objected to 
this, but consented to excision, which was performed. The 
impossibility of maintaining the extremity of the femur in 
a fixed position, the rotating muscles of the thigh con- 
stantly turning it outwards, together with the profuse sup- 
puration, caused death on the thirtieth day. 2 

2. In 1839, Anthony White operated on a boy seven 
and a half years old, " whose left leg had been caught in 
a wheel, which twisted and dislocated the condyles of the 
thigh-bone through a large transverse wound above the 
bend of the knee-joint and extending a little in front of 
either hamstring. The condyles were forced through the 
legs of his duck trousers, and the attempts to replace the 
bone were without success ; the end of the femur was 
therefore sawn off, and the shaft immediately dropped into 
its place." Either from the neglect which, in the night 
following the operation, permitted him to slip through a 
hole made in his bed that he might evacuate his bowels 
without displacing the limb, and so " to be found on the 
floor in the morning,' ' or for other reasons, it was not 
until the expiration of eighteen months that the boy was 

i Med. Times and Gaz., May 18, 1861. 
2 Blackmail's Velpeau, Vol. II. p. 492. 



132 EXCISION OF THE KNEE-JOINT. 

able to walk. After the operation, a large abscess formed 
over the head of the tibia, and twenty months from the 
time of the injury the articulating extremity of that bone 
exfoliated and came away. In 1847, the lad is described 
as stout and healthy, but no mention is made of his pow- 
ers of locomotion. 1 

This case, which, like a preceding one, shows the con- 
sequences of partial excision, deserves comment for the 
sake of the surgeon, Anthony White, the first to« excise 
the hip-joint, one of the earliest to excise the knee, — and 
that too at a time when the operation was under special 
obloquy, — and, after Dupuytren (1812), the first in Eu- 
rope (1816) to excise the lower jaw. 

3. Mr. Chalmers, of Liverpool, October 13, 1859, ex- 
cised the right knee of a man forty-four years old, for a 
wound into the joint, complicated with a compound, com- 
minuted fracture of the patella and rupture of the liga- 
ments. The excision was a complete one, but the patient 
died of fever, exhaustion, and suppuration, forty-one days 
after the operation. 2 

4. A boy, eight years of age, came under the care of 
Mr. Canton, of Charing Cross Hospital, with the shaft of 
his femur torn from its yet cartilaginous epiphysis by the 
entanglement of his limb in the spokes of a cart-wheel. 
It was impossible to keep the boy still in his bed ; slough- 
ing ensued, and the femur protruded. The patient being 
evidently in a failing condition, the ends of the femur and 
tibia, with the patella, were removed, and a thin slice was 
also taken from the free end of the femur, that the parts 
might come into better apposition. The boy's restless- 
ness did not, however, abate, and after a short time the 
end of the bone again protruded, and another portion was 
sawed off. Subsequently he progressed favorably, but the 
union was such as not to admit of utility ; and five months 
after the excision the limb was amputated, at the request 

i South's Chelius, Vol. II. p. 982. 
2 Lancet, Dec. 17, 1859. 



EXCISION FOR DEFORMITY. 133 

of the lad's friends. From this operation he recovered at 
the end of a fortnight. 1 

5. At a meeting of the Pathological Society of London, 
February 7th, 1860, the last-named surgeon exhibited the 
epiphysis of the femur, the patella, and a thin slice of the 
tibia, removed on account of an accident similar to the 
preceding one, which occurred the October previous, and 
was followed by a similar history. The case was under 
treatment at the time of the report, but the subject of it 
eventually did well, and at the end of a year was able to 
walk twelve miles without fatigue. 2 

Such is the discouraging catalogue of excisions of the 
knee-joint for injury, — twelve cases, but three of which 
proved successful, and one of these only at the end of 
twenty months, during the whole of which time dead bone 
was discharged. 

Results derived from so small a number of operations do 
not authorize a comparison with those of amputations, the 
mortality following which, when performed at the lower 
third of the thigh for traumatic cause, is 56.6 per cent, in 
military practice (Macleod) ; and 60 per cent for primary, 
and 75 per cent for secondary amputations, in hospital 
practice (Bryant). 



EXCISION FOR DEFORMITY. 

The operation of excising the disorganized joint has 
been not infrequently undertaken, to relieve the deformity 
produced by the varying degrees of angular anchylosis of 
the knee, and once, by Mr. Humphry of Cambridge, Eng- 
land, for that resulting from a fractured patella, badly 
united. 3 

1 Lancet, Aug. 28, 1858 ; and Trans, of the Lond. Path. Soc, 1859, p. 232. 

2 Lancet, Feb. 18, 1860 ; Dublin Quarterly, Feb. 1861, p. 74. 

3 Med.-Chir. Trans., Vol. XLI. p. 211. 

12 



134 EXCISION OF THE KNEE-JOINT. 

The angular anchylosis to which reference is here made 
is not the secondary and simply muscular contraction 
which belongs to almost all diseased knees, but that which 
is the result of reparative processes, persisting after all 
active disease has ceased, and which, though ordinarily 
fibrous, in some cases eventually becomes osseous. 

The operation first practised by Dr. Gurdon Buck of New 
York, October 12, 1844, 1 has taken the place of that of Dr. 
J. R. Barton, who applied to the knee, in 1835, 2 the same 
mode of operating which he had already used for the hip 
in 1826. This last method, though subsequently adopted 
by other operators (Gibson, Mutter, Pancoast, Post, Burr, 
Warren, Townsend), leaves an unsightly deformity, result- 
ing from the prominence of the knee, thrown forward in 
bending the limb, at the point of the bone's section just 
above the joint. It is, therefore, at least in an operative 
point of view, advantageously superseded by Buck's pro- 
cedure, consisting in the removal of a wedge-shaped piece, 
which includes what were once the articulating surfaces of 
the femur and tibia. 

Although differing in essential particulars from an ex- 
cision which opens a joint possessing in a greater or less 
degree some of its normal conditions, the gravity of the 
operation is not thereby diminished. The difficulties be- 
longing to its execution, and the mortality which accom- 
panies it, render its performance, upon a person otherwise 
in perfect health, a matter of serious importance. The 
accompanying table of cases, being all of which I can find 
any report, although comprising but a small number, is 
still sufficient to show the truth of this statement. 

We have here 19 cases, with 10 recoveries ; 8 fatal ter- 
minations, in every instance more or less directly due to 
the operation itself, and one amputation for long delayed 
non-union of the ends of the bones. 



i Am. Journ. of Med. Sc, Oct. 1845, p. 277. 
2 Ibid., Feb. 1838, p. 332. 



EXCISION FOR DEFORMITY. 



135 



Age. 


Sex. 


Result. 


Authority. 




M. 


Recovered in 9 mos. 


Barwell on Dis. of Joints, p. 457. 




M. 


Recovered. Union very slow. 


Med. Times & Gaz., Oct, 24, '57. 


21 


M. 


Died 30th day. Retention of urine. 


Lancet, Dec. 18, 1858. 


18 


M. 


Died, 7th day, of pyaemia. 


Med. Times & Gaz., Feb. 24, '55. 




M. 


Recovered. On crutches in 3 mos. 


N.York Med. Times, Mar. 1854. 


14 


M. 


Recovered. Walked in 4 mos. 


Med. and Surg. Reporter, Mar. 
16, 1861, p. 648. 


19 


M. 


Died, 30th day, of pneumonia. 


Lancet, Jan. 9, 1858. 


40 


M. 


Recovered rapidly. 


St. Louis Med. and Surg. Journ., 
May, 1861, p. 211. 


22 


M. Recovered. On crutches in 3 mos. 


Am. Journ. of Med. Sc, Oct/45. 


14 


M. 


Died, 13th day, of tetanus. 


Mass. Gen. Hosp. Records. 


24 


M. 


Died, 4th day, of vomiting. 


Dublin Quarterly, Feb. 1857. 


47 


M. 


Recovered. On crutches in 1 mo. 


Med.-Chir.Trans.,Vol. 41 , p. 195. 


8 


M. 


Died, 3d day, of shock. 


Pemberton on Excision, p. 16. 


19 


M. 


Recovered. Left off crutches in 3 


Boston Med. and Surg. Journ., 






mos. 


April 14, 1859. 


23 


M. 


Recovered in 6 mos. 3 in. short- 


Schillbach, Resect, der Knoch., 






ening. 


p. 57. 


30 


M. 


Died, 20th day, of exhaustion. 


Ibid., p. 104. 


12 


M. 


Recovered. Walked fairly in 5 mos. 


Med.-Chir.Trans.,Vol.41,p.l96. 


9 


M. 


Amp. for non-union at end of 27 


Trans, of Lond. Path. Soc, 1 859. 






mos. 


p. 220. 


— 


— 


Amp. followed by death from gan- 


Brit. Med. Journ., Jan. 5, 1861. 




grene. 





According to Mr. Bryant, in 18 amputations of expe- 
diency, in the thigh, with which these excisions may very 
properly be contrasted, the deaths were only one in 3.16 
cases. 1 

It is not easy to explain this great mortality, except by 
attributing it to the difficulties and complications which 
almost universally attend the operation. The immediate 
extension of the limb, as in all cases where the hamstring 
tendons have been long contracted, presents an obstacle 
not easily overcome. I have known the operation, in more 
than one instance, to occupy an hour and upwards in its 
performance. The division of tendons, the removal of sev- 
eral successive slices of bone, and the application of very 
considerable force, do not always suffice to extend the 
limb, or bring the sawed surfaces into close apposition. If 
this is only partially effected, and a gap remains between 
the bones, a source of irritation is established which endan- 
gers the life of the patient. 



i Med.-Chir. Trans., Vol. XLI1. p. 71, 



136 EXCISION OF THE KNEE-JOINT. 

It may be a question whether gradual extension should 
not be adopted, as in Barton's method, or whether that 
operation had not better have remained in vogue, since its 
success seems to have been considerably greater than that 
of the one now under consideration. Dr. Sargent, of Phil- 
adelphia, gives a series of nine operations with but a single 
fatal result ; x and, according to Se'dillot, 2 of fifteen cases 
operated on by Mayor, of Wurzburg, only one died. 

The extreme rarity of true osseous anchylosis, and the 
success of mechanical treatment in the hands of English 
and German surgeons (especially Mr. Brodhurst and the 
MM. Langenbeck, of Hanover and Berlin), in cases where 
only fibrous anchylosis exists, warrant the expectation of 
results at least as satisfactory without, as with an opera- 
tion. 



EXCISION FOR DISEASE. 

Although a case cited by Wachter, where, in the course 
of several months, a large portion of the articular surface 
of the knee-joint was extracted in fragments through fistu- 
lous openings, and terminating successfully, 3 would seem 
to suggest the application of this excision to necrosis of the 
knee-joint, whenever such a rare event occurs, yet I am 
aware of no instance in which it has been put in execution. 
The successful removal by J. F. Heyfelder of the upper 
epiphysis of the tibia, separated by an injury, in a boy ten 
years old, and the sawing off of the corresponding end of 
the shaft after suppuration was established, is the nearest 
approach to such an operation of which I have knowledge. 4 
With the exception of three operations, performed for 
acute inflammation of the articulation, 5 and the anticipated 

1 Miller, Principles of Surg. (2d Am. ed.) 3 De Artie Extirp., p. 97. 

2 Med. Op., (2 me ed.,) Tom. I. p. 536. 4 Operationslehre, u. s. w., p. 41. 
5 Lancet, June 20, 1857. Dublin Quarterly, Feb. 1857, p. 18, Case 19. Pem- 

berton, On Excision of the Knee-Joint, p. 19, Case 5. 



EXCISION FOR DISEASE. 137 

success of two of which in no wise lessens the entire con- 
demnation that such a step deserves, excision of the knee- 
joint has probably never been undertaken for any other 
than chronic disease, or " white swelling." The records of 
Guy's Hospital show that*' the knee is, of all the joints, the 
most frequent seat of this affection. 1 Considering its ordi- 
nary characteristics, together with the unfavorable progno- 
sis which attends it, and the frequent necessity for amputa- 
tion, the introduction of an operation calculated to avoid 
such a contingency demands careful investigation. 

The questions when and in what sort of cases excision 
shall be adopted, have been already sufficiently considered 
(p. 8), and need only be alluded to now, to say that the 
circumscribed form of tubercular deposit in the articular 
extremities of the bones, to which alone it is insisted by 
Mr. Price that excision is applicable, (operations when it is 
of the infiltrated sort, he says, are sure to be unsuccess- 
ful, 2 ) is of extreme rarity, seldom if ever being met with. 
It may also be observed, that it is questionable whether 
the so-called infiltrated disease is really tubercular. 

Apart from those previously given, there are other and 
numerous considerations which suggest themselves with re- 
gard to the application of this particular excision. Set- 
ting aside the danger to life, the offices of the limb on 
which it is performed require results in the matters of 
length, consolidation, and ability to sustain superincum- 
bent weight, which are not exacted in the upper extremity. 
The leg can be spared, as a means of progression, better 
than the hand as an instrument of prehension, and more 
successful substitutes have been contrived to make its loss 
less disastrous. There can be no doubt, however, that a 
limb from which the knee-joint has been excised is some- 
times far better than any artificial one ; but whether, with 
Mr. Fergusson, we shall adopt the conclusion, that " in 

1 Bryant, op. cit. 

2 P. C. Price, Contributions to the Surgery of Diseased Joints, with especial 
Reference to the Operation of Excision, No. I. The Knee, (London, 1859,) 
p. 12, et seq. 

12* 



138 EXCISION OF THE KNEE-JOINT. 

eight cases out of every ten, under the age of twenty or 
thirty, in which disease of the articulating surfaces of the 
knee-joint seems incurable, the operation of resection should 
be preferred to that of amputation," 1 is a question not to 
be answered without deliberation. 

The abuses to which the operation has been subjected, 
as shown by the two tables of Mr. Butcher of Dublin, — 
there being 19.35 per cent of unfavorable results (deaths 
and subsequent amputations) in the first table, of 31 cases, 
not omitting those which were under treatment, and 31.37 
per cent in the second, of 51 cases ; his struggles to make 
the mortality of excisions so much less than that of ampu- 
tations ; the reluctant admission of Mr. Price of London, 
that the real mortality is about the same as, or even in 
favor of amputation, — the obvious fact being put out of 
sight that excisions are performed upon selected cases, and 
that their results ought not, therefore, to be compared on 
an equal footing with those of amputation of the thigh, 
practised upon all sorts of cases, no matter how unfavor- 
able ; the headlong manner in which some surgeons have 
entered upon its performance, acknowledged by them in 
their sensitiveness to the accusation, and in the contro- 
versial correspondence which the charge, or its insinua- 
tion, has in many instances called forth ; the discussion 
at the Medico-Chirurgical Society to which the report of 
Mr. Humphry's thirteen cases gave rise ; — these are, all 
of them, circumstances which tend to prove that excision 
of the knee-joint is not an operation so successful as could 
be desired. 

With all Mr. Park's enthusiasm for his " new method," 
he was still moderate enough to say : " I beg I may not be 
so misunderstood, as to have it supposed that I am san- 
guine enough to imagine that the method I have been 
recommending will succeed in every case. I know the 
contrary, and fear that, after the chirurgic art lias done 
all that it is capable of, many of these diseases will still 

1 Pr. Surg., (4th ed., Lond. 1857,) p. 457. 



EXCISION FOR DISEASE. 139 

occur in which amputation can alone save the life of the 
patient." 1 

In the discussion alluded to as following Mr. Hum- 
phry's paper, it was made a subject of remark, that 
whilst that gentleman had operated thirteen times with 
thirty per cent of subsequent amputation, not a single 
case adapted to excision had been admitted at St. Bar- 
tholomew's Hospital, with a surgical service of 389 beds, 
for five years ; and at the Orthopedic Hospital, where a 
great number of diseased joints are seen, since 1851, 
(seven years,) not a single case had been found suitable for 
this operation ; nor, so far as was known, had there been an 
instance of its performance in the upper ranks of society. 
The opinion was also expressed by one eminent surgeon, 
that, when the statistics were collected from various sources, 
it would be found that the operation was really more dan- 
gerous than amputation. 2 

It is apparent, therefore, that a wide difference of opin- 
ion exists as to the success and propriety of this excision. 
The better to ascertain towards which side the weight of 
testimony leans, I have collected the facts of a large num- 
ber of operations. I am aware of no tables which approach 
the following one in the number of its cases, except those 
of Mr. Price of London, 3 and Dr. 0. Heyfelder of St. Pe- 
tersburg. 4 Although Mr. Price's cases are not presented 
in a tabular form, or enumerated in detail, it may not be 
uninteresting to know what results he has arrived at. 
They may be stated as follows. 

From the date of Mr. Fergusson's first operation, July 
20, 1850, to the end of December, 1858, the knee had been 
excised 160 times, six of the operations being for deformity 
and one for accident. Of these, Mr. Price says, 32 were 
fatal, or one case in every five ; a result which corresponds 
with that which Mr. Butcher derived from his tables, com- 

1 Jeffray's Park and Moreau, p. 43. 

2 Med. Times and Gaz., March 20 and May 29, 1858. 

8 Contributions to the Surgery of Diseased Joints, &c., &c. 

4 Operationslehre und Statistik der Resectionen, ( Wien, 1861,) p. 122. 



140 EXCISION OF THE KNEE-JOINT. 

piled two years before. Subsequent amputation was re- 
quired 18 times, and was followed in one case by a fatal 
result, — which, added to those above given, increases a 
little the ratio of mortality, making it one in 4.84 cases. 
To make a comparison between excision and amputation, 
Mr. Price cites from Teale on " Amputation by Rectan- 
gular Flaps," and from Mr. Bryant's " Causes of Death 
after Amputation." The former says that 169 amputa- 
tions of the thigh, for disease, were performed in the Lon- 
don hospitals during the three years 1854-1857. Of these 
38 proved fatal, or about one in 4.5 cases. During the 
same years, 134 amputations of the thigh for disease were 
performed in the provincial hospitals, with 33 deaths, or 
about one in four cases. Mr. Bryant, however, in statistics 
drawn from Guy's Hospital, has shown that one in 5.5 cases 
was the proportion of fatal results in pathological amputa- 
tions of the thigh ; and that, for chronic disease of the 
knee-joint, only one case out of seven proves fatal. From 
all of which Mr. Price somewhat boldly concludes, that, 
" comparing the results of excision of the knee-joint with 
those of amputation for disease, the percentage of success- 
ful cases is certainly in favor of the former operation." 
(p. 42.) 

During the first six months of 1859, Mr. Price had col- 
lected particulars of 24 additional cases, of which 4 were 
fatal from the operation, and 6 required subsequent am- 
putation ; of these latter 3 died. 1 This would increase 
the mortality to one death in 4.6 cases, which hardly sus- 
tains the remark quoted at the close of the preceding par- 
agraph. Dr. Heyfelder's table comprises 183 cases, 179 
of which had reached a definite result, viz. 125 recover- 
ies and 54 deaths. Amongst these recoveries, however, 
are included 15 amputations successfully performed sub- 
sequent to the excision. These figures exhibit a mortal- 
ity of one death in 3£f cases. 

1 R. Druitt, Principles and Practice of Modern Surgery, (8th ed., Lond. 
1859,) p. 749. 



EXCISION FOR DISEASE. 



141 



As a matter of curiosity, I present separately those cases 
of excision performed prior to the reintroduction of the 
operation, believing that the circumstances under which 
they were performed properly exclude them from a table 
to be relied upon, at the present time, for conclusions. 
These cases are 30 in number ; 17 of them proved fatal, 
although in 2 death occurred at the expiration of two and 
three years. In one case subsequent amputation was ren- 
dered necessary, and in 12 the patients recovered ; 4 of 
them, however, with a nearly or quite useless limb. 



Date. 


Surgeon. 


Sex. 


Age. 


Result. 


Authority. 


1762 Filkin. 


M. 




Recovered in 3 mos. 


Jeffray's Park and Moreau. 


1781 Park. 


M. 


33 


1 year. 


Ibid. 


1789 Park. 


M.|30 


Died in 4 mos. 


Ibid. 


1792 Moreau,Sen 


M. 


20 


" 3 mos. 


Ibid. 


1809 Mulder. 


F. 


34 


Died in 3^- mos. 


Wachter de Art. Ext., p.30. 


1811 Moreau,Jun. 






Recov. Walked badly. 


Diet, des Sc. Med , Tom. 47, 
Art. Resection. 


1816 Roux. 


M. 


32 


Died in 19 days. 


Diet. en 30 vols., Art. Genou. 


1823 Crampton. 


F. 


23 


Recov. Limb useless. 


Dubl. Hosp. Rep., IV. 203. 


1823 Crampton. 


F. |23 


Died in 3 yrs. unheal'd. 


Ibid., p. 196. 


1829 Syme. 


M. 8 


Recov. Limb useless. 


On Exc. of Joints, p. 135. 


1829 Syme. 


F. 


7 


Died in 11 days. 


Ibid., p. 138. 


1830 Jaeger. 


M 


28 


Recovered in 1 year. 


Arch. Ge'n. de Med., Dec, 
1853, p. 721. 


1832 Textor,d.V. 


F. 


26 


Died. 


O. Heyfelder's Tab., No. 14. 


1832 Fricke. 


F. 


8 


Recovered. 


Ibid., No. 15. 


1832 Fricke. 






Died. Pyaemia. 


Ibid., No. 16. 


1832 Fricke. 






Died. Hectic. 


Ibid., No. 17. 


1835 Demme. 


M. 36 


Recovered in 4 mos. 


Ibid., No. 19. 


1836 Fricke. 


F. 1 18 


Recov. Limb deform'd. 


Ibid., No. 18. 


1839 , Textor, d. S. 


F. 


32 


Died in 4 mos. from 


Ibid., No. 20. 










exhaustion. 




1840 


Lang. 


M. 


24 


Died in 8 wks.of pyaem. 


Ibid., No. 21. 


1842 


Textor, d.V. 


F. 


23 


Recovery complete. 


Ibid., No. 22. 


1842 


Demme. 






Died of pyaamia. 


Ibid., No. 23. 


1842 


Demme. 






it (< 


Ibid., No. 24. 


1845 


Textor, d.V. 


F. 


44 


Amputat'n ; recovery. 


Ibid., No. 25. 


1845 


Textor, d. S. 


M 


29 


Died in 6 wks. of pyaem. 


Ibid., No. 26. 


1848 


Heusser. 


M. 20 


Recovered in 4^ mos. 


Ibid., No. 27. 


1849 


Heusser. 


M. 


32 


Partial resect. Died in 
2 yrs. of tuberculosis. 


Ibid., No. 28. 


1849 


Heusser. 


M. 


6 


Recovered in 7 weeks. 


Ibid., No. 29. 


1849 


Textor, d. S. 


F. 


29 


Died in 13 days of ex- 
haustion. 


Ibid., No. 31. 


1849 


Heyfelder. 


M. 


21 


Died of pvaemia in 15 


J. F. Heyfelder, Amp. und 






days. 


Resect., p. 163. 



The following table comprises excisions performed sub- 
sequently to 1850, and includes only such as have been 
undertaken for chronic disease of the joint. 



142 



EXCISION OF THE KNEE-JOINT. 



No. Authority. 


Sex. 


Age. 


Termination. 


Time under 
Treatment. 


1 Dublin Quarterly, Feb. 1855. 


M. 


21 


Died. 


8 days. 


2 Ibid. 


F. 


25 


Recovered. 


1 year. 


3 i Ibid. 


M. 


11 


(< 


2 years. 


4 Ibid. 


F. 


30 


Died. 


13 days. 


5 Ibid. 


M. 


7 


Recovered. 


15 mos. 


6 Ibid. 


M. 


14 


" 


1 year. 


7 Ibid. 


M. 


20 


it 


20 mos. 


8 Ibid. 


F. 


21 


a 


6 mos. 


9 Ibid. 


M. 


42 


it 


1 year. 


10 Ibid. 


M. 


20 


It 


3 mos. 


11 j Ibid. 


M. 


12 


" 


10 weeks. 


12 


Ibid. 


F. 


28 


Died. 


16 days. 


13 


Ibid. 


M. 


9 


Recovered. 


7 mos. 


14 


Ibid. 


M. 


28 


" 




15 


Ibid. 


M. 


H 


tt 


101 mos. 
2| mos. 


16 Ibid. 


M. 


14 


tt 


17 B.& F. Med.-Chir.Eev.,Oct.'57, p. 313. 


M. 


16 


Amputat. 




18 Pemberton on Excision. 


M. 


9 


Recovered. 


82 days. 


1 
19 Dublin Quarterly, Feb. 1855. 


M. 


18 


Died. 


24 days. 


20 Ibid. 


M. 


33 


Recovered. 


8 mos. 


21 


Ibid. 


M. 


7 


" 


1 year. 


22 


Pemberton on Excision. 


M. 


12 


<( 


9 mos. 


23 


Dublin Quarterly, Feb. 1855. 


M. 


12 


Died. 


12 days. 


24 


Ibid. 


M. 


,Hr 2 


Recovered. 


115 days. 


25 


Ibid. 


F. 


15 


Amputat. 




26 


Ibid. 


M. 


10 


Recovered. 


7 mos. 


27 


Ibid. 


M. 


8 


it 


13 mos. 


28 


Ibid. 


F. 


20 


a 


6 mos. 


29 


Med. Times and Gaz., Jan. 5, 1861. 


M. 


6 


u 


6 mos. 


30 


Ibid. 


M. 


6 


it 


4 mos. 


31 


Dublin Quarterly, Feb. 1857. 


M. 


10 


Amputat. 


24 days. 


32 


Ibid. 


M. 


10 


Recovered. 


7 mos. 


33 


Ibid. 


M. 


10 


Died. 


5 days. 


34 


Ibid. 


F. 


12 


Recovered. 


27 mos. 


35 


Ibid. 


F. 


20 


tt 


11 mos. 


36 


Ibid. 


M. 


14 


Amputat. 


9 days. 


37 


Ibid. 


F. 


27 


Recovered. 


1 year. 


38 


Ibid. 


M. 


4 


a 




39 


Ibid. 


M. 


11 


u 


22 mos. 


40 


Ibid. 


M. 


33 


Amputat. 


7£ mos. 


41 


Ibid. 


M. 


18 


Died. 


17 days. 


42 


Ibid. 


M. 


34 


Amputat. 


38 days. 


43 


Ibid. 


F. 


9 


Recovered. 


2 mos. 


44 


Ibid. 


F. 


47 


Died. 


18 days. 


45 


Ibid. 


F. 


5 


Unreliev'd. 


15 mos. 


46 


Ibid. 


M. 


18 


Recovered. 


3 mos. 


47 


Ibid. 


M. 


22 


it 


5 mos. 


48 


Edinb. M. and S. Journ., Jan. 1861. 


F. 


26 


Died. 


6 days. 



EXCISION FOR DISEASE. 



143 



Ultimate Result. 



Remarks. 



Requires artificial support. 3 in. short. 
Walks, runs, and jumps. 4 in. short. 

Walks, runs, & kicks football in 15 mos, 
Walks well without a stick. 3 in. short. 
Can walk 6 miles. Works as a painter. 
Walks well without assistance. 
Walks with ease and celerity. 
Walks 5 miles easily at end of 20 mos. 
Walks well at end of 20 mos. 



Perfect, bony anchylosis. 

Walks with firmness. 

In 15 mos. walks, runs, and plays. 

Useless limb. 7 in. shortening. 



Walks 1 2 to 15 miles without fatigue. 
Limb anchylosed. 

Limb an encumbrance. 9 in. short. 

In 5 mos. walked a mile. 

"Not yet permitted to rest on limb." 
Eventually walks & runs withlittle halt. 
Walks and runs without difficulty. 
Moves about with aid of a chair. 
Walks well without assistance. 
Good anchvlosis. 



Can walk, run, and hop. At end of 18 
mos. fistulae and ulcerations. 



Walks only with a crutch. 

6 inches shortening." 
Walks without assistance. 



At least 



Walks 3 or 4 miles without much diffi- 
culty. Sinuses still exist at end of 
17 mos. 

" Very fair leg " at end of 21 mos. 

Walks without a crutch. 



" Runs about famously." 

"Leg ought to be amputated." 

Walks without crutches. 

Walks easily with a high-heeled shoe. 



Pyaemia. Patella removed. 

Anchylosis imperfect. Left knee. 

2 yrs. after operation sound and whole 

Dysentery. 

Patella and 4 in. of bone removed. 

Patella removed. 



Left knee. 



Death from pyaemia. Patella and 3^- 

inches removed. Left knee. 
Patella gouged. 

Patella and head of fibula removed. 
Patella removed. 

2 inches removed. Patella shaved. 
Right knee. 

Diarrhoea ; phthisis. 

Patella removed. Left knee. 

Capacity for walking not stated. Pa- 
tella scraped. 

3^ inches removed. Left knee. 

Phthisis. 

Patella pared. Right knee. 

Recovery at end of 10 months. 

Patella gouged. Right knee. 

Left knee. 

Joint quite healed. 

After 6 years 5 inches shortening. 

Patella gouged. 

Recovery at end of 4 mos. Patella 

gouged. Left knee. 
Patella gouged. 

Exhaustion. 
Left knee. 

Patella removed. Left knee. 
Recovery in 6 weeks. 
Patella removed. 



Patella gouged. Right knee. 

Recovery in one month. 

Pyaemia. 

Recovery in 3 mos. 

Patella gouged. Left knee. 

Exhaustion. 

Partial excision. 

Patella scraped. 

Patella scraped. Right knee. 

Pyaemia. 



144 



EXCISION OF THE KNEE-JOINT. 



No. 
49 

50 

51 
52 
53 
54 
55 
56 
57 
58 
59 
60 
61 
62 
63 
64 
65 

66 
67 

68 
69 
70 
71 
72 
73 
74 
75 
76 
77 
78 
79 
80 
81 
82 
83 
84 
85 
86 
87 

88 
89 
90 
91 
92 

93 
94 
95 
96 
97 
98 



Authority. 



Dublin Quarterly, Feb. 1857. 



Ibid. 

Ibid. 

Ibid. 

Ibid. 

Ibid. 

Ibid. 

Ibid. 

Ibid. 

Ibid. 

Ibid. 

Lancet, Nov. 27, 1858. 

Dublin Quarterly, Feb. 1857. 

Ibid. 

Ibid. 

Med. Times and Gaz., 1857. 

Dublin Quarterly, Feb. 1857. 

Ibid. 

Med. Times and Gaz., July 30, 1859. 

Ibid., Mar. 21, 1857. 

Ibid., Apr. 30, 1859. 

Ibid. 

Ibid. 

Ibid. 

Ibid. 

Lancet, July 9, 1859. 

Ibid., Jan. 2 and May 14, 1859. 

Ibid., Apr. 9, 1859. 

Med. Times and Gaz., Oct. 17, 1857. 

Ibid. 

Lancet, July 25 and Sept. 27, 1857. 

Med. Times and Gaz., Oct. 17, 1857. 

Ibid. 

Ibid., Dec. 5, 1859. 

Lancet, Dec. 18, 1858. 

Med. Times and Gaz., May 8, 1858. 

Ibid. 

Ibid., June 5, 1858. 

Ibid., May 29, 1858, and July 20, 

1861. 
Ibid., Feb. 6, 1858. 
Glasgow Med. Journ., Jan. 1856. 
Med. Times and Gaz., Jan. 16, 1858. 
Ibid., Aug. 21, 1858. 
Ibid. 

Dublin Quarterly, Nov. 1857. 
Med. Times and Gaz., May 3, 1856. 
Ed. Month. Journ., Vol. III. p. 721. 
Dublin Quarterly, Feb. 1859. 
Lancet, Apr. 24, 1858. 
Ibid., July 17, 1858. 



Sex. 

F. 

F. 

F. 
M. 
F. 
F. 
F. 
M. 
M. 
M. 
M. 
M. 
M. 
M. 
M. 
F. 
F. 

M. 
M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

F. 

F. 

M. 

F. 

F. 

M. 

F. 

M. 

F. 

M. 

M. 

F. 

M. 

F. 

M. 

M. 
F. 

M. 

M. 
F. 
F. 
F. 
M. 
F. 



Age. 
20 



30 
15 
19 
15 

26 
18 

9 
29 
20 

9 
27 
12 
37 
27 
26 

26 
31 

39 

7 
14 
10 
15 

8 
36 

30 
27 
40 
14 
34 
10 

35 
19 
37 
16 
13 



Termination. 



Recovered. 



Amputat. 

Died. 

it 

Recovered 

Died. 

Amp. Died 

Recovered. 
it 

Amputat. 

Died. 

Recovered. 

Died. 
« 

Recovered. 

Died. 
Amp. Died. 

Amputat. 

it 

Amp. Died. 
a a 

Amputat. 

Recovered. 

Died. 

Amputat, 

Died. 



Time under 
Treatment. 



Recovered. 

n 

Amputat. 
Died. 



Recovered 



Died. 
Recovered 



Died. 

M 

Recovered. 

Amputat. 

Recovered. 



5 mos. 



6 weeks. 

5 mos. 

3 mos. 

7 mos. 

6 mos. 

10 days. 
15 weeks. 

2 mos. 

4 mos. 
109 days. 
27 mos. 
24 hours. 

5 mos. 

11 weeks. 

6 weeks. 
1 year. 

13 days. 



6 weeks. 
9 mos. 



4 mos. 

5 mos. 

2 weeks. 
1\ mos. 

23 days. 

3 weeks. 

6 weeks. 
10 days. 

3 mos. 

7 mos. 

6 weeks. 
17 days. 
19 days. 
21 days. 

9 weeks. 

3 mos. 



29 days. 

7 mos. 
4 mos. 

6 mos. 
28 days. 
21 days. 
11 mos. 

8 mos. 
3£ mos. 



EXCISION FOR DISEASE. 



145 



Ultimate Result. 


Remarks. 


Walks well and strongly, but with a 


Patella scraped. Eight knee. 


halt. Some motion between bones 




at end of 17 mos. 






Recovery at end of 5 mos. Patella 




left. Left knee. 




Phthisis. 




Partial excision. Left knee. 


Walks with a stick and help of another. 


Patella removed. 


Walks without stick or crutch. 


Patella removed. Left knee. 




Pyaemia. Left knee. 




Died at end of 16 weeks. 


Walks easily with a high-heeled shoe. 


Left knee. 


Walks without crutches. 


Patella removed. Left knee. 




Recovered in 5 mos. Left knee. 




Recovered. Right knee. 




Shock. 


Walks fairly. 






Exhaustion. Right knee. 




Anaemia. Right knee. 


Can bear any amount of fatigue. 


Patella removed at second operation. 

Left knee. 
Pyaemia. 






Exhaustion, 4 days after amputation. 




Left knee. 




Recovered at end of 6 weeks. 




Pyaemia, 5 days after amputation. . 




Pyaemia, 8 days after amputation. 




Patella removed. 




Pyaemia. Patella removed. 




Recovered. 




Erysipelas. Pat. removed. L. knee. 




Pyaemia. 


On crutches in 6 weeks. 




" An excellent limb." 


Patella shaved. 




Phthisis. Right knee. 




Pyaemia. 




Exhaustion. 




Exhaustion. 


Walks with little lameness. 1£ in. re- 


Patella left. Left knee. 


moved. At end of 4 yrs. 4£ in. short. 




Walks with a firm, straight limb. 






Phlebitis. 


In 2 yrs. walks without noticeable limp. 




Walks well without crutch or stick. 


Patella removed. Left knee. 


Can walk 3 miles with a stick. 


Patella makes an unsightly projec- 




tion. Left knee. 


Firm anchylosis. 






Diarrhoea and exhaustion. L.knee. 




Exhaustion. Left knee. 


Firm anchylosis. 


Patella removed. 




Recovered in 3 mos. 


"All that could be desired." 


Patella removed. Right knee. 



13 



146 



EXCISION OF THE KNEE-JOINT. 



No. 


Authority. 


Sex. 


Age. 


Termination. 


Time under 
Treatment. 


99 


Am. Journ. Med. Sc., July, 1859. 


F. 


58 


Recovered. 


10 mos. 


100 


Bost. Soc. for Med. Imp., Vol. 3, p.151 . 


M. 


20 


it 


1 year. 


101 


Ibid., p. 179. 


M. 


32 


« 


5 mos. 


102 


Mass. Gen. Hosp. Records, 1859. 


F. 


19 


Died. 


3 mos. 


103 


Ibid. 


F. 


13 


Recovered 


1 year. 


104 


Glasgow Med. Journ., Oct. 1859. 


F. 


18 


<< 


6 mos. 


105 


Med. Times and Gaz., June 5, 1858. 


F. 


45 


ti 


8 mos. 


106 


Ibid. 


F. 


3 


tt 




107 


Lancet, April 24, 1858. 


M. 


5 


tt 


3 mos. 


108 


Med. Times and Gaz., May 8, 1858. 


F. 


5 


Died. 


22 days. 


109 


Ibid. 


M. 


25 


Recovered. 


7 mos. 


110 


Ibid. 


M. 


35 


Amputat. 


3 mos. 


111 


Ibid. 


M. 


10 


«( 


3 mos. 


112 


Ibid., June 5, 1858. 


F. 


18 


Recovered. 


13 mos. 


113 


Ibid. 


F. 


27 


" 


2^ mos. 


114 


Ibid., April 16, 1859. 


M. 


24 


Died. 


24 days. 


115 


Ibid. 


F. 


15 


" 


4 days. 


116 


Med.-Chir. Trans., Vol. XLI. p. 211. 


M. 


13 


Recovered. 


10 mos. 


117 


Med. Times and Gaz., Oct. 8, 1859. 


M. 


11 


" 


7 mos. 


118 


Ibid., Oct. 15, 1859. 


M. 


26 


it 


2 mos. 


119 


Edinb. M. & S. Journ., Nov. & Dec'59. 


F. 


21 


tt 


3^ mos. 


120 


Lancet, Dec. 3, 1859. 


F. 


13 


Died. 


76 days. 


121 


Med.-Chir. Trans., Vol. XLI. p. 211. 


F. 


23 


Amputat. 


10 mos. 


122 


Med. Times and Gaz., Apr. 30, 1859. 


F. 


4 


Recovered. 


7 weeks. 


123 


Glasgow Med. Journ., Oct. 1859. 


M. 


23 


Died. 


15 days. 


124 


Med. Times and Gaz , Apr. 21 , 1860. 


M. 




Amputat. 


7 days. 


125 


Pemberton on Excision, p. 13. 


M. 


7 


Died. 


19 days. 


126 


Ibid., p. 17. 


F. 


30 


tt 


2j mos. 


127 


Mass. Gen. Hosp. Records, 1859. 


M. 


8 


Recovered. 


3 mos. 


128 


Med. Times and Gaz., Apr. 21, 1860. 


M. 


7 


tt 


7 mos. 


129 


Ibid. 


M. 


12 


tt 


6 mos. 


130 


Ibid. 


F. 


7 


" 


7 mos. 


131 


Ibid. 




5 


Died. 




132 


Ibid. 


F. 


19 


" 


9 days. 


133 


Ibid. 


F. 


10 


Recovered. 




134 


Ibid., April 28, 1860. 


M. 


11 


Amputat. 


8 mos. 


135 


Ibid. 


M. 


33 


(< 


3 mos. 


136 


Ibid. 


M. 


4 


tt 


9 mos. 


137 


Ibid. 


F. 


36 


tt 


1 year. 


138 


Ibid., May 5, 1860. 


M. 


25 


tt 


3 weeks. 


139 


Glasgow Med. Journ., Oct. 1859. 


M. 


13 


Recovered. 


15 mos. 


140 


Ibid. 


M. 


8 


" 


9 mos. 


141 


Ibid. 


F. 


35 


Died. 


24 days. 


142 


Ibid. 


M. 


19 


Amp. Died. 


5 mos. 


143 


Ibid. 




10 


Recovered. 


4 mos. 


144 


Ibid. 




14 


Died. 


29 days. 


145 


Med. Times and Gaz., June 2, 1860. 


M. 


14 


" 


26 days. 


146 


Vidal, Vol. V. p. 732. 


M. 


19 


tt 




147 


Scbillbach, p. 45. 


M. 


33 


" 


17 days. 


148 


J. F. Heyfelder, p. 162. 


M. 


17 


Amputat. 


11 weeks. 


149 


Mass. Gen. Hosp. Records. 


M. 


13 


Recovered. 


13 weeks. 


150 


Lancet, July 7, 1860. 


M. 


»* 


<( 


2 years. 


151 


Med. Times and Gaz., Aug. 4, 1860. 


M. 


15 


Amp. Died. 


4 mos. 


152 


Lancet, Aug. 4, 1860. 


M. 


37 


Died. 


7 mos. 



EXCISION FOR DISEASE. 



147 



Ultimate Result. 


Remarks. 


Walks with difficulty. 


Patella removed. 


Walks with ease. 


Right knee. 


Walks as well as any one. 


Right knee. 




Exhaustion. Left knee. 


Walks with tolerable ease. 


Left knee. 


"Anchylosis perfect." 




Beginning to walk. 




it (< 


Patella removed. Left knee. 




Exhaustion. Left knee. 


Walks firmly. 


Right knee. 




Recovered. Right knee. 




Recovered. 


Walks with a stick. 


Left knee. 


Walks well without a stick. 


Patella removed. Left knee. 




Diphtheria and irritation. 




Irritation. 


Walks 6 miles without a stick. 




Walks, runs, plays at leap-frog. 


Patella removed. 


Left with bony anchylosis. 


Patella removed. Left knee. 


Walks with little lameness. 


Patella gouged. 




Diarrhoea. Patella removed. R.knee. 




Recovered. 


Walks without assistance. 






Pyaemia. Left knee. 




Phthisis. Patella removed. R.knee. 


Climbs about like other boys. 






Patella removed. Right knee. 


Walks 3 or 4 miles without fatigue. 


Patella removed. Right knee. 


Walks without assistance. 


Right knee. 




Pyaemia. Left knee. 


Recovered. 




" 


Failing health ; hectic. 


t( 


No anchylosis. Disease returned. 


(C 


Failing health. Profuse discharge. 


Walks only with crutches. 


Left knee. 




Diarrhoea. 




Died of phthisis a year after the am- 




putation. Patella gouged. R.knee. 




" Of shock." 




Died of fatty liver. Patella removed. 




Left knee. 




Phlebitis of bone. 




Pyaemia. Extensive excision. L.knee. 




Recovery in one month. 


Walks very fairly. 


Right knee. 


Still walks with a splint. 


Patella removed. Left knee. 




Died from exhaustion ten days after. 




Right knee. 




Exhaustion. Left knee. 



148 



EXCISION OF THE KNEE-JOINT. 



No. 
153 


Authority. 


Sex. 


Age. 


Termination. 


Time under 
Treatment. 


Lancet, Aug. 4, 1860. 


M. 


6 


Recovered. 


8 mos. 


154 


Ibid. 


M. 


8 


(< 


15 mos. 


155 


Ibid. 


M. 


23 


" 


7 mos. 


156 


Med. Times and Gaz., Nov. 10, 1850. 


F. 


9 


tt 


4 mos. 


157 


Ibid, Dec. 15, 1860. 


M. 


25 


Amputat. 


7 mos. 


158 


Pemberton on Excision, p. 31. 


M. 


28 


Recovered. 




159 


Med. Times and Gaz., Sept. 8, 1860. 


M. 


10 


it 


16 mos. 


160 


Am. Med. Times, Sept. 22, 1860. 


F. 


30 


tt 


7 mos. 


161 


Med. Times and Gaz., Nov. 17, 1860. 


F. 


12 


Amputat. 


4 mos. 


162 


Barwell on Dis. Joints, p. 460. 


M. 


33 


Recovered. 


3 mos. 


163 


Ibid., p. 461. 


M. 


8 


tt 


8^ mos. 


164 


Ibid., p. 462. 


M. 




" 


5 mos. 


165 


0. Heyfelder's Table, No. 34. 


M. 


26 


n 


5 mos. 


166 


Ibid., No. 35. 


F. 


24 


Died. 


35 weeks. 


167 


Ibid., No. 36. 


F. 


18 


Amp. Died. 


4 days. 


168 


Ibid., No. 43. 


M. 


33 


" " 




169 


Ibid., No. 48. 


M. 


20 


Died. 


14 days. 


170 


Ibid., No. 49. 


M. 


30 


Recovered. 




171 


Ibid., No. 50. 


F. 


10 


Died. 


35 weeks. 


172 


Ibid., No. 51. 


F. 


26 


Recovered. 


26 weeks. 


173 


Ibid., No. 52. 


M. 


20 


" 




174 


Ibid., No. 53. 


M. 


18 


Died. 




175 


Ibid., No. 54. 


F. 


26 


tt 




176 


Ibid., No. 55. 


M. 


49 


« 




177 


Ibid., No. 56. 


F. 


23 


Recovered. 




178 


Ibid., No. 69. 


M. 


16 


Died. 


10 days. 


179 


Ibid., No. 91. 


M. 


23 


Recovered. 




180 


Ibid., No. 99. 


M. 


26 


Amputat. 




181 ! Ibid., No. 100. 


F. 


34 


Recovered. 




182! Ibid., No. 101. 


M. 


33 


Died. 


17 days. 


183 1 Ibid., No. 140. 


M. 


35 


Recovered. 


6 mos. 


184 Ibid., No. 141. 


M. 


17 


Died. 


13 days. 


185 | Ibid., No. 143. 


M. 


18 


tt 


2 mos. 


186 j Ibid., No. 144. 


M. 


13 


Amputat. 


49 days. 


187 Ibid., No. 167. 






Died. 


19 days. 


188 ! Ibid., No. 174. 


M. 


30 


Recovered. 




189 


Ibid., No. 175. 


M. 


22 


a 




190 


Ibid., No. 176. 


F. 


28 


Died. 


5 weeks. 


191 


Ibid., No. 177. 


M. 


68 


" 


6 weeks. 


192 


Ibid.. No. 178. 


M. 


15 


Recovered. 




193 


Ibid., No. 1 83. 


M. 


43 


Died. 


4 days. 


194 


Ibid., No. 46. 






tt 




195 


Ibid., No. 47. 






Amputat. 




196 


Ibid., No. 67. 






Recovered. 




197 


Ibid., No. 68. 






<< 




198 


Ibid., No. 172. 






" 




199 


Ibid., No. 173. 






tt 




200 


Med. Times and Gaz., Apr. 27, 1861. 


F. 


23 


Died. 


3 mos. 


201 


Ibid. 


M. 


40 


Amp. Died. 


11 days. 


202 


Dublin Quarterly, May, 1860, p. 457. 


M. 


20 


Recovered. 


3 mos. 


203 


Am. Med. Times, June 8, 1861. 


F. 


21 


cc 


1 year. 


204 


Lancet, May 18, 1861. 


F. 


17 


tt 


16 mos. 


205 


Med. Times and Gaz., June 1, 1861. 


F. 


191 


Amputat. 


9 mos. 


206 


Ibid. 


M. 


51 


tt 


56 days. 


207 


Bost. M. & S. Journ., July 1 1, 1 861. 


M. 


16 


" 


1 year. 


208 


Med. Times and Gaz., Aug. 31, 1861. 


M. 


18 


Recovered. 


4 mos. 



EXCISION FOR DISEASE. 



149 



Ultimate Result. 


Remarks. 


Walks with ease and comfort. 


Patella gouged. Right knee. 


Walks with ease and rapidity. 


Patella gouged. 


Able to get about. 


Patella gouged. 


Walks without crutch or stick. 


Right knee. 




Recovered rapidly. 


Firm bony union taken place. 


Died of phthisis at end of 15 months. 


Fibrous union. Much shortening. 


Patella removed. Right knee. 


Crooked limb. 




Firm union. Walks well. 


Patella removed. Left knee. 




Recovered. Patella removed. 


Walks with a stick. 


Patella removed. 


Walks with a stick. 


Patella removed. 


Works as a gardener. 


Right knee. 


Firm union. 






Phthisis. 




Died at end of 10 months. 




Died of Bright's dis. at end of a year. 




Pyaemia. 


Useful limb. 




Re-excised after 20 wks. for non-union. 


Exhaustion 15 wks. after 2d operation. 


Useful limb. 






Six inches removed. 




Phthisis. 




Phthisis. 




Pyaemia. 


Complete success. 






Pyaemia. 


Useful limb. 






Recovered. 


Fibrous union. 




Useful limb. 






Exhaustion. 


1 


Recovered. 




Exhaustion. 




Marasmus. 




Phthisis. 




Pyaemia. Patella removed. L. knee. 




Pyaemia. 




Recovered. 




Hemorrhage and suppurat'n. R. knee. 




Died 15 days after amputat'n. R. knee. 


Walks well without pain. 


Patella scraped. Left knee. 


Useful limb; much shortened. 


Left. knee. 


Walks without assistance. 


Re-excised at end of 1 1 mos. L. knee. 




Recovery. Patella pared. Left knee. 




Recovery. Patella pared. Left knee. 




Five inches of femur removed. Tibia 




not touched. 


Walks without crutches. 


Patella removed. Right knee. 



13 



150 



EXCISION OF THE KNEE-JOINT. 



I am indebted to the compilation of Mr. Butcher for 
sixty-five of the foregoing cases, and to that of 0. Heyfelder 
for thirty-five ; the rest were derived from various sources, 
all of which are indicated in the appropriate place. 

Of the 208 cases of which the table is made up, 129 
were males, and 69 females ; in 10 the sex is not stated. 
Of 75 excisions in which the fact is noted, 29 were of 
the right, and 46 of the left knee. Of the whole num- 
ber, 106 recovered and 60 were fatal. In 42 cases the 
patients underwent subsequent amputation, from which 26 
recovered and 9 died, while in 7 the result is not given. 
The youngest subject in the present table was 3 years of 
age, and the oldest 68 ; the former recovered, the latter 
died. The average age of the patients in whom the opera- 
tion failed, i. e. who died or underwent amputation, was 
25/j years. Of 85 who recovered, the average age was 
19f| years. It is asserted that this excision has been 
performed upon a child only 2 years old. 1 

Of the patients recovering, 65 obtained a useful limb ; 
in 14 the result can be considered only partially success- 
ful, the limb being more or less useless ; in 27 the simple 
statement of "recovery" is all which is given. By a 
" useful limb," is understood one in which there is a solid, 
straight anchylosis, or, at least, a perfectly firm, fibrous 
union between the tibia and femur. There should be 
little shortening ; and the patient should possess the abil- 
ity to walk, to a considerable extent, without pain, and 
without more assistance than that derived from a cane or 
splint. 

In the fatal cases the causes of death were as follows, 
viz. : — 



Pyaemia .... 
Exhaustion 


17 
14 


Anaemia . 
Marasmus . 


. 1 
1 


Phthisis .... 


9 


Shock . 


. 2 


Diarrhoea and dysentery 

Phlehitis 

" Irritation " 


3 
2 
2 


Erysipelas 

" Fatty Liver " 

Causes not stated . 


1 

. 1 
7 



i Am. Med. Times, Sept 15, 1860. 



EXCISION FOR DISEASE. 151 

Death occurred in 1 case at the end of 8 J months. 



a 


a 


1 


a 


u 


it *7 it 


a 


a 


1 


a 


a 


a 5 a 


a 


a 


1 


a 


U 


" 3i " 


a 


a 


3 


a 


it 


a 3 « 


a 


u 


4 


a 


in from 9 to 11 weeks. 


u 


u 


5 


a 


a 


3 to 8 " 


a 


a 


14 


a 


u 


19 to 29 days. 


a 


a 


13 


a 


a 


12 to 18 " 


a 


a 


8 


u 


a 


5 to 10 " 


a 


a 


3 


a 


a 


1 to 4 " 



In 6 cases the period which elapsed is not stated. 

The causes which led to subsequent amputation were 
return of the disease in the bones, the condition of the 
neighboring soft parts, and the constitutional irritation 
produced by pain, suppuration, <fec, &c. In the 9 fatal 
cases, death was caused by pyaemia in 2, exhaustion in 2, 
phthisis in 1, Bright's disease in 1, and in 3 the cause is 
not stated. In 5 instances the fatal. result occurred within 
15 days of the amputation ; in 2, at the end of one year ; 
and in 2, at the end of 10 months and 16 weeks respec- 
tively. 

The following figures show the beneficial effects of re- 
moving the patella. 

There were 8 deaths and 5 amputations in the 61 cases 
where the patella was either removed or pared, which is 
a percentage of 21.31 ; and this, contrasted with the per- 
centage of death and amputation in the other cases, — 
viz. 60.54, — gives 39.23 per cent in favor of those where 
it was removed. 

Of 48 cases where the patella or its cartilage was re- 
moved, and in which recovery took place, the duration of 
treatment was 225 days. Supposing it to have been left 
in the 38 other cases of recovery (and it is known to have 
been in most of them) in which the duration of treat- 
ment is stated, and where it was 255ff days, we have a 
contrast in favor of removal of the patella of about 30 
days. 



152 EXCISION OF THE KNEE-JOINT. 

There are then, according to the preceding table, 60 
deaths in 208 excisions, or one in every 3 T 7 5 cases. Count- 
ing the deaths, amputations, and those cases terminating 
in a useless limb, 105, or about one half, are failures of 
the original operation. Of these failures, 12 were of the 
right knee, and 21 of the left. In 72 cases the side is 
not mentioned. This result corresponds in a very strik- 
ing manner with that derived from Dr. Heyfelder's table, 
which exhibits a mortality of one in 3-££ cases, and also 
with the summary given by Dr. Krackowizer, of New 
York, viz. 233 excisions with 63 deaths, and 21 subse- 
quent amputations, or a mortality of one in 3|| cases. 1 

It has been already stated, that, according to Mr. Bry- 
ant, 2 one amputation in seven for chronic disease of the 
knee-joint proves fatal ; and this result is confirmed by the 
statistics of St. George's Hospital, 3 which give precisely the 
same mortality, and, so far as they go, by those of the Mas- 
sachusetts General Hospital, where, according to Dr. George 
Hayward, of 30 annotations of the thigh for white swell- 
ing, 4 were fatal.* Whether, therefore, we take these fig- 
ures, or those of Mr. Teale, already cited (p. 140), derived 
from the provincial hospitals of Great Britain, it will be 
seen that favorable conclusions with regard to this excis- 
ion are not sustained by the analysis of cases which has 
just been given, but that the preponderance on the side of 
safety is nearly two to one in favor of amputation. 

i Am. Med. Times, Sept. 25, 1860. 

2 Med.-Chir. Trans., Vol. XLII. p. 71. 

a Med. Times and Gaz., April 6, 1861. 

4 Surgical Reports and Miscellaneous Papers, (Boston, 1855,) p. 142. 



SUBSEQUENT GROWTH OF THE LIMB. 153 



SUBSEQUENT GROWTH OF THE LIMB. 

If the manner in which the growth of a bone in length 
takes place is recalled, — viz. by additions to the two ends 
of the diaphysis, through the ossification of a cartilaginous 
stratum existing between each of these and the epiphysis, — 
it will be understood that, in theory at least, the removal of 
the end of a bone, in a young person, beyond this dividing 
line, ought to cause some arrest of its growth. So con- 
vinced of this are nearly all the later writers on excision, 
that the extent of removal in children is made the matter 
of special caution. This has been particularly insisted 
upon by Mr. Humphry, an authority in osteology entitled 
to great respect. 1 He calls attention to the thinness of the 
epiphysis of the tibia, and reminds operators that epiphyses 
do not increase in thickness in proportion to the growth of 
the shaft, but remain nearly the same throughout the 
period of adolescence. What are the facts bearing upon 
this point? 

The limbs of the boy, eight years old, operated on by Mr. 
Syme, in 1829, had an unequal growth, and that which 
was the subject of the operation gradually diminished in 
length, till, twenty years after, it wanted several inches of 
reaching the ground. 2 This occurrence led to the sarcastic 
remark, that "in Sir Patrick Crampton's only successful 
case, the famous one of Anne Lynch, ' who could walk the 
length of a day/ it appeared from the bones, bequeathed 
to the operator by the patient, after her death, and which 
are now in the Lincoln's Inn Fields Museum, that the tibia 
and os femoris were united at a right angle, so that the 
progressive motion must have been of a very rare and 
remarkable kind ; while the subject of Mr. Park's never to 

1 A Treatise on the Human Skeleton, including the Joints, (Cambridge, 
Eng., 1858,) p. 44; also Lancet, April 20, 1861. 

2 Contributions to the Pathology and Practice of Surgery, (Edinburgh, 1848,) 
p. 225. 



154 EXCISION OF THE KNEE-JOINT. 

be too frequently quoted case probably made a better 
appearance climbing up the rigging of his ship, like the 
quadrumanous inhabitant of a tropical forest, than he 
would have done as a biped on terra firma." 1 

Mr. Price says that he is aware of one or two in- 
stances where the cutting away of the epiphyses has led to 
an expression of dissatisfaction at the result of the opera- 
tion. Mr. Butcher endeavors to prove that any apprehen- 
sions on this point are unfounded. Mr. Keith, writing to 
the last-named gentlemaii in answer to inquiries, says 
(September 30, 1856) : " John Hay's limb, operated on at 
the age of nine, (two inches being removed), in November, 
1853, is plump and growing in length " ; 2 and yet, three 
years after making the above report, he writes to Mr. Pem- 
berton that there is a shortening of seven inches. 3 So, in 
a case operated on by Mr. Pemberton himself, where three 
and a quarter inches were removed, the leg, which at the 
end of a year was of equal length with its fellow, six years 
later is shrunk, blighted, and shortened nine inches. In- 
stead of being the " useful limb " reported by Mr. Butcher, 
" it cannot be regarded," according to the operator, " other- 
wise than an encumbrance, little better than a sad deform- 
ity." 4 The fear of such a shortening, and apparently, from 
the drawing accompanying the report, the actual existence 
of it, is noticeable in the details given of a case operated on 
at the age of eleven and a half years, by Mr. Heath of Lon- 
don, two years prior to the report. 5 In the case of a boy, 
six years old, operated on by Mr. Henry Smith, the union 
was not osseous, and there was a shortening of two and a 
quarter inches. Five and a half years afterwards, there 
was perfect anchylosis, but the shortening amounted to five 
inches, and the boy walked only by the aid of a very cum- 
brous apparatus. 6 A lad, thirteen years old, whose knee 

1 Edinb. Month. Journ. of Med. Sc, July, 1853. 

2 Dublin Quarterly, Feb. 1857. 8 On Excision, p. 8. 

4 On Excision of the Knee-Joint, p. 6. 5 Lancet, July 7, 1860. 



6 



Med. Times and Gaz., Jan. 5, 1861. 



SUBSEQUENT GROWTH OF THE LIMB. 155 

was excised by Mr. Frith of Norfolk, only one and seven 
eighths inches being removed, and in whom the recovery 
was rapid and the union osseous, at the expiration of 
four years had four and a half inches of shortening, and, 
although able to walk a considerable distance, had been 
obliged to abandon his former occupation of farm-servant 
for that of a shoemaker. 3 Such instances as these, few 
though they be, are a commentary on those cases the 
later history of which is unknown. 

On the other hand, one would think that cessation in 
growth ought to be a more common occurrence, were this 
a certain consequence of too free excision in the early years 
of life. It might be asked, why we do not hear of this 
accident happening to the upper extremity ; but there it 
would not necessarily render the limb useless, and hence, 
if it does really ensue, may pass without special notice. 
A certain amount of growth undoubtedly takes place 
through the agency of the epiphysial cartilage, remain- 
ing untouched, at the opposite extremity of the bones. 
In the early part of 1859, there was a discussion at 
the Societe de Chirurgie, of Paris, " sur Pallongement 
des os aprSs les amputations chez les enfants," and a 
number of cases of apparent growth of this sort were 
referred to. It was evident, however, that the question 
was a new one to those present, and, notwithstanding 
French loquacity, but little was said, and still less infor- 
mation elicited. 2 

Roux in his thesis (p. 13) quotes LeVeille, " Memoire 
sur les Maladies qui afifectent les bouts des Os apres l'Am- 
p'utation," as authority for the assertion, "On a vu des 
pieces d'os, de la longueur de plusieurs pouces, se faire jour 
a travers la cicatrice, deja ancienne, d'un moignon bien 
conform^." Mr. Stanley amputated the arm of a boy aged 
five ; the wound healed, and left a well-formed stump. 
Three years afterwards, the bone protruded, and an inch of 

1 Med. Times and Gaz., July 20, 1861. 

2 L'Union Medicale, 17, 24, et 31 Mai, et 7 Juin, 1859. 



156 EXCISION OF THE KNEE-JOINT. 

apparently new growth of bone was removed. Nine years 
after the amputation, the boy returned again with a similar 
growth. " This prolongation," says the reporter, " for it 
is not a protrusion, is a growth of the bone continuous with 
a growth of the lad's body." 1 Mr. Curling amputated a 
boy's arm. He made a good recovery, and the end of the 
bone was well covered. Three years afterwards the hu- 
merus projected three fourths of an inch, but of a calibre 
smaller than the shaft of the bone. This was considered a 
growth of the bone with the growth of the boy. 2 A boy, 
twelve years old, whose arm had been amputated seven 
years, presented himself to Mr. Skey. Six months previ- 
ously the bone began to emerge, and now projected an 
inch ; it retained its vitality and was covered with peri- 
osteum. The end of the bone being cut off, the parts 
rapidly healed. 3 A young woman, aged eighteen, whose 
arm had been removed during childhood, the stump heal- 
ing kindly and remaining healthy, noticed that it had for 
the last three or four years been gradually becoming con- 
ical ; at last, from its point, the end of the humerus pro- 
truded. " There was no retraction of muscular substance, 
but clearly an outgrowth of bone, the rest of the stump 
being healthy." Mr. Hilton cut off three inches of the 
bone, and the patient did well. 4 

Mr. Palmer, the manufacturer of artificial limbs, whose 
familiarity with the results of amputation must be very 
considerable, informs me, that he is not aware that " con- 
ical stump " is more frequent, after amputations in child- 
hood, than it is after those of adult life. A statement to 
this effect, and explained by the supposition that the bone 
continues to grow, has, however, been made by M. Guer- 
sant, of the hospital for sick children, Paris 5 ; and also by 

1 Lancet, Feb. 28, 1857. 

2 Ibid., May 16, 1857. 

3 Med. Times and Gaz., June 2, 1860. 

4 Lancet, Aug. 4, 1860. 

5 L'Union Medicale, 31 Mai et 7 Juin, 1859. 



SUBSEQUENT GROWTH OF THE LIMB. 157 

Mr. Pemberton, who mentions a very striking case in illus- 
tration. 1 

From these statements on both sides of the question, it 
seems fair to conclude that extensive removal may lead to 
a cessation of growth in the bone ; and of this proof is 
given. We also have a single case of its arrest, viz. Mr. 
Syme's, where only the articulating surfaces were re- 
moved. 2 The negative of the question, extensive removal 
without cessation of growth, depending upon a few cases 
of which no very long-continued history is given, remains 
unproved ; and although it appears that a certain amount 
in length is always added to the shaft of a bone, there is no 
evidence that this is ever sufficient to compensate for any 
considerable shortening. During adolescence, therefore, 
operations requiring removal of bone beyond the line of 
epiphysial junction are liable to terminate ultimately in an 
unfavorable manner. 

In a number of cases in which the limb has not kept up 
its growth, fibrous anchylosis alone has taken place. This 
led Mr. Mackenzie of Edinburgh to suggest that it might 
be itself the cause of the arrest ; 3 and Mr. Pemberton, after 
an investigation of the subject, concludes that " adequate 
growth is more likely to be attained where care has been 
taken to remove as small a portion of the articular extrem- 
ities as possible, and where true anchylosis has resulted." 4 
A more probable explanation of this accident seems likely, 

1 Excision of the Knee-Joint, p. 11. 

It is to be borne in mind, that in the lower extremity the benefit of an 
increase in length, such as has just been described, is in part counterbalanced 
by the obliquity of the upper epiphysis of the femur ; any growth from that end 
being nearly lost to the limb by its addition in an oblique direction. In the 
tibia, however, the growth is in the long axis of the bone, and is therefore all 
gain. This statement is supported by Mr. Pemberton's case of shortening, where 
the femur lost twice as much as the tibia ; and also by Mr. Keith's, where the 
femur lost four and a half inches, and the tibia only two and a half inches. In 
both these cases about the same amount was removed from each bone. 

2 Pemberton on Excision of the Knee-Joint, p. 11. 

3 Monthly Journ. of Med. Sc, June, 1856. 

4 On Excision of the Knee-Joint, pp. 12, 13. 

14 



158 EXCISION OF THE KNEE-JOINT. 

however, to be found in the experiments of M. Oilier, if 
these should be confirmed by repetition. This gentleman 
claims to have shown that the two epiphyses do not effect 
the same proportion of the growth of long bones, and that 
those which achieve the most do not correspond in the two 
extremities. He arrives at the conclusion, that in the upper 
extremity, for the arm and fore-arm, the epiphyses farthest 
from the articulation of the elbow grow the most ; whilst 
in the inferior extremity, for the bones of the thigh and 
leg, the epiphyses nearest to the knee increase to the great- 
est extent. Therefore, at the elbow, excision cannot cause 
arrest of development to any considerable degree, since at 
this point it is by the epiphyses at the other extremity that 
the greatest growth is effected. At the knee, on the other 
hand, it will be much more likely to happen, since the 
femur and tibia lengthen more by the epiphyses forming 
that joint, than by those at the opposite extremity of the 
bones. For the same reason, other things being equal, ex- 
cision of the head of the humerus will lead ultimately to 
more shortening than that of the head of the femur, and 
that of the wrist to more than that of the ankle. 1 



OPERATION AND AFTER-TREATMENT. 

Various plans have been devised for performing excision 
of the knee-joint. That in most common use, and the one 
adopted by Moreau, consists of two lateral incisions and a 
transverse one just below the patella. The operation in- 
troduced by Mackenzie has perhaps been equally popular, 
viz. a " horse-shoe-shaped " incision, extending from one 
side of the joint to the other, the convexity of which is 
directed downwards. 2 The elliptical incision introduced 

1 Journal de Physiologie de B. Sequard, Vol. IV. No. 13, p. 87. 

2 Edinb. Monthly Journ. of Med. Sc, June, 1853, p. 526. 



OPERATION AND AFTER-TREATMENT. 159 

by Mr. Syme, and including the patella between its two 
curved lines, 1 although occasionally practised, is objection- 
able, since it removes a portion of the integument. 

But no incision is better, because none is more simple, 
than a transverse one on a line with the articulating sur- 
face of the tibia, extending half-way round the limb. First 
suggested by Park in his second letter, it has been adopted 
recently by Mr. Fergusson of London, 2 and by Mr. Watson 
of Glasgow. 3 It freely exposes the articulation without 
unnecessary linear incisions, and the dependent situation of 
its two ends favors the discharge of matter, and permits 
the division of the hamstring tendons, whenever that step 
is thought desirable, without any additional puncture or 
incision. The surgeon who is curious in details will find 
that in the papers of Mr. Butcher the steps of the oper- 
ation of excision are discussed with all the minuteness 
he can possibly desire. 

In one or two instances the ligamentum patellae has 
been preserved undivided. This course was suggested by 
Mr. Mackenzie, 4 but first put in practice by Mr. Jones 
of Jersey. 5 The proceeding was a complicated one, and 
of difficult execution. It was accomplished by drawing 
the patella and its ligament over the internal condyle 
whilst the limb was extended ; then, forcibly flexing the 
joint, the articular surfaces of both bones were brought 
into view, and readily excised. 

Any saw is suitable for use in this operation. Great 
claims have been made for the superiority of special in- 
struments, such as Mr. Butcher's or Mr. Graham's, but 
I have yet to learn their advantage over the narrow blade 
which usually accompanies the common bow-saw of am- 
putating-cases. It is not necessary to reverse the edge 

1 On the Excision of Joints, p. 136. 

2 Med. Times and Gaz., Nov. 27, 1858. 

3 Glasgow Med. Journ., Oct. 1859. 

4 Edinb. Monthly Journ. of Med. So., June, 1853, p. 526. 

5 Med.-Chir. Trans., Vol. XXXVII. p. 69. 



160 EXCISION OF THE KNEE-JOINT. 

of this, nor to cut from behind forward. As Mr. Syme 
says, it is both much easier and much safer to expose the 
bone sufficiently to permit the application of the saw by 
free incision, than to overcome the difficulties attending 
a less complete exposure by any mechanical contrivances. 1 
The division of the soft parts and of the crucial ligament 
permits the head of one bone, by flexing the limb, to be 
opposed to that of the other, in such a way that the sec- 
tion can be accomplished against it without any risk to 
the vessels. The soft parts immediately connected with 
the bones should be sawed, rather than too carefully dis- 
sected away, so that the periosteum may be as little inter- 
fered with as possible. The removal of a thin, superficial 
slice, and the subsequent use of the gouge till a good 
bleeding surface is obtained, will, in most cases adapted 
to excision, obviate a shortening of the limb which, if the 
saw alone were used, would perhaps be very considerable. 
A bevelling of the section, at the expense of the bone pos- 
teriorly, allows the limb to unite in a slightly flexed po- 
sition, more favorable for walking than one which is per- 
fectly straight. 

It has recently been proposed, in all cases where any 
considerable amount needs removal, either from the ex- 
tent of the disease or the nature of a fracture, that the 
section of the bones should be made, not in the usual 
transverse direction, but by carrying the saw through each 
bone obliquely, either from above downwards and from 
before backwards, or from below upwards and from be- 
fore backwards. Whenever such a course will include 
the parts to be excised, and in very many cases it must, 
a large amount of bone may be removed without causing 
the great shortening which a transverse section compris- 
ing the same extent would necessitate. The common dif- 
ficulty in making the two transverse surfaces parallel is 
also obviated by the oblique section. But whether it 
admits of ready application in practice, or whether the 

1 On the Excision of Joints, p. 23. 



OPERATION AND AFTER-TREATMENT. 161 

ingenuity of the method in theory is not counterbalanced 
by the practical difficulty of keeping bones thus sawed in 
proper apposition, which their resemblance to an oblique 
fracture at once suggests must be the case, I am unable 
to say, as it probably has never been adopted in this coun- 
try. The introduction of this innovation is claimed both 
for Billroth of Zurich and Pelikan of St. Petersburg. 1 

It is a matter of great importance to remove all the 
diseased synovial membrane, wherever it can be reached ; 
if left, it is often the cause of much irritation, and leads 
to the formation of fistulae, which are kept up by the dis- 
charge of a pseudo-synovial fluid. 2 

In this connection it may be proper to speak of partial 
excision, equally to be condemned here as in the elbow. 
The large cartilaginous surface of either bone, if in a 
condition sufficiently healthy to be left, must be, if not 
removed, the seat of a long and painful exfoliation, or 
the source of profuse suppuration and irritation. In Mr. 
Butcher's second series, Case No. 16, the head of the tibia 
was left, " on purpose to see if it could be possible to 
save it, in our present state of knowledge, without remov- 
ing it from the body" (sic; the case is reported by an 
Irishman). A year afterwards the unsatisfactory return 
is, that " the head of the tibia ought still to be excised, 
although amputation might be thought of by some sur- 
geons, or a firm joint might be got by removing an inch 
and a half of the head of the tibia." 3 So in Case 23 of 
the same series, where only the end of the femur was re- 
moved, the patient gradually failed, with profuse suppu- 
ration, and died two months after the operation. 4 In a 
case operated on by Dr. Cooper of San Francisco, Cal., 
the result (amputation at the end of a year, on account of 
the burrowing of pus) was perhaps as much due to par- 

1 0. Heyfelder, op. cit., p. 125. 

2 See a case of Mr. Cadge's in Med. Times and Gaz., Aug. 4, 1860. 

3 Dublin Quarterly, Feb. 1857, pp. 16, 53. 

4 Ibid., p. 21. 

14* 



162 EXCISION OF THE KNEE-JOINT. 

tial excision, as to the extent to which the bone was re- 
moved. 1 In 20 partial excisions of the knee, — i. e. of either 
the end of the femur, end of the tibia, or of the patella, — 
collected by 0. Heyfelder, there were 8 deaths and 4 
amputations. The patella alone appears to have been re- 
moved with tolerable success only in cases of injury, for 
which it was done 6 times with a single death ; but in 5 
instances of its removal for caries there were 3 secondary 
amputations, and one death. 2 

In like manner, unfortunate results not infrequently fol- 
low when, in an excision, the patella is left unremoved. 
There are many instances where its subsequent removal 
was rendered necessary; 3 and a comparison has already 
been instituted (p. 151) between the cases in which it 
was left and those where it was excised, resulting, both 
as to the success and the length of treatment, greatly in 
favor of the latter. Its retention converts the operation 
into a partial excision, and in no way contributes to the 
greater usefulness of the limb. The unconditional re- 
moval of this bone is therefore universally advised. 

In apposing the sawed surfaces, especial pains should be 
taken that the soft parts do not bulge up from behind, and 
interpose between the two bones. This may be avoided 
by first adjusting the posterior edges of the section. In 
doing this, care should be taken that the bones do not press 
too tightly against each other, since this may itself be a 
cause of trouble. 

The removal of bone being accomplished, it is not al- 
ways easy to bring the limb by extension into a straight 
position, the tight hamstrings of the flexed knee — so 
characteristic of disease of that joint, and always present 
in a deformity which requires the operation — offering a 
formidable obstacle, not always removed by the sacrifice 
of successive sections of the bone. I have seen as many 

1 Boston Med. and Surg. Journ., July 11, 1861. 

2 Operationslehre, u. s. w., p. 135. 

8 Lancet, Feb. 27, 1857 ; Med. Times and Gaz.. Dec. 5, 1857. 



OPERATION AND AFTER-TREATMENT. 163 

as ten slices removed to effect this, and even then with 
only an imperfect accomplishment of the desired end. 
The division of the hamstring tendons, as first recom- 
mended by Mr. Butcher, 1 — especially of that of the bi- 
ceps, which, by its insertion into the head of the fibula, is 
more at fault than the others, — has been often practised 
as a regular step of the operation, to obviate not only this 
difficulty, but also the tendency to backward displacement, 
brought about by the action of their muscles. Their sec- 
tion may be accomplished, as already stated, through the 
principal incision of the integuments, and no advantage 
seems to arise from their formal subcutaneous division. 
Barton, in his operation, which it is true was somewhat 
different from that under consideration, took two months 
to straighten the limb. 2 J. F. Heyfelder suggests that, 
when any difficulty occurs, extension should be deferred 
for a time, and cites a case where it was not undertaken 
until ten days after the excision. Unfortunately for his 
illustration, the patient died five days afterwards of pyae- 
mia. 3 An extension kept up until the muscles are tired 
out may do much to effect straightening of the limb, as 
the same course does in fracture of the thigh. At any 
rate, it is a method which should be thoroughly tried be- 
fore severer measures are adopted. 

To facilitate discharge from the interior of the wound, 
Mr. Holt of London proposes that the popliteal space 
should always be perforated at the time of the operation. 4 
The ends of the large incision can, however, be easily car- 
ried far enough backwards to render this procedure un- 
necessary. From the vicinity of the large vessels, such a 
course could hardly fail to increase the dangers of the op- 
eration, as well as to aggravate the tendency to oedema of 
the leg, which almost always occurs. This sometimes per- 

1 Dublin Quarterly, Feb. 1855, p. 58. 

2 Am. Journ. of Med. Sc., Vol. XXI. (1838,) p. 336. 
8 Ueber Resect, und Amp., p. 163. 

* Med. Times and Gaz., Mar. 22, 1856. 



164 EXCISION OF THE KNEE-JOINT. 

sistent symptom is due to the blocking up of the veins 
by the inflammatory processes going on, and is alleviated 
by position, bandages, etc. 

The inhalation of ether is especially adapted to the op- 
eration of excision of the knee, saving the shock to a 
worn-out patient, and adding to the ease with which it is 
performed. What can be more strikingly in contrast with 
the operation, as it is now witnessed, than the description 
given by Crampton of the sufferings of his patient ? " Four 
strong assistants could with the utmost difficulty retain 
her upon the table ; the poor girl, whom terror seemed 
to have deprived of her reason, struggled so violently with 
both limbs, that it was with a degree of labor and anxiety 
such as I had never before experienced, that I at length 
succeeded in detaching the divided extremity of the fe- 
mur." 1 

Hemorrhage, although rarely severe, is occasionally of 
a grave character, either at the time of the excision or 
secondarily. Mr. Syme says the operation is a bloody 
one, and has thereby given great offence to its advocates. 2 
Hemorrhage, " from an artery as large as the radial," re- 
quired attention, and unstitching of the wound, in Mr. 
Butcher's first case ; 3 and in this gentleman's second table, 
three instances of severe hemorrhage, one rendering the 
patient pulseless, are mentioned, viz. Nos. 13, 26, and 
28. 4 Mr. Pemberton's sixth patient nearly bled to death. 5 
This experience shows how carefully the wound should 
be searched, and all oozing vessels tied. 

Inflammation of the shaft of the bone is an accident lia- 
ble to occur. This has been spoken of in connection with 
excision of the elbow, and has also followed excision of the 
head of the femur. Mr. Pemberton reports its occurrence 
after excision of the knee, " the thigh-bone becoming two 
or three times greater than its fellow." 6 

1 Dublin Hosp. Rep., Vol. IV. p. 205. 2 Lancet, Nov. 15, 1856. 

3 Dublin Quarterly, Feb. 1855, p. 26. 4 Ibid., Feb. 1857. 

6 On Excision of the Knee-Joint, p. 21. 6 Ibid., p. 26. 



OPERATION AND AFTER-TREATMENT. 165 

Absolute immobility during the after-treatment is all-im- 
portant ; even slight motion interferes with the subsequent 
solidity of the limb, and movement of the bones upon each 
other is liable to bring back the disease. Confinement to 
bed, therefore, must be strict and prolonged ; and for a 
length of time proportionate to the rate of progress there 
should be the added restraint of an apparatus, the nature 
and name of which is unimportant, provided it fulfils the 
condition of preserving immobility in the limb to which it 
is applied. During the second dressing, if it is attempted 
before the parts become fixed, displacement of the tibia 
backwards is liable to occur, unnoticed by the surgeon, who 
may discover it only when it is too late to be remedied. 
A considerable length of time after the operation should 
therefore be allowed to elapse before this is performed ; 
and the intervals between subsequent dressings should also 
be as long as they can possibly be made. In a number of 
instances, the later published reports of English surgeons 
show these to have been sometimes several weeks. The 
consequences of inattention to the proper steadiness of 
the limb, or of inability to maintain this, are shown in 
secondary amputations, inordinate degree of shortening, 
deformity, and permanent mobility. 

During the slow process of healing, the wound frequently 
takes on a peculiar character, assuming, in spots, a fungous 
appearance, which is kept up by a slight discharge of mat- 
ter or serosity, or by small bits of exfoliating bone. It 
may be questioned whether much mischief is not done, and 
perhaps this very state produced, by the bone-dust left in 
the wound and crowded into the cancellous spaces by the 
action of the saw. This must be discharged as dead mat- 
ter, and an effort should therefore be made to effect its 
removal at the time of the operation, either by a sponge, a 
stream of water from a syringe, or perhaps by means of a 
brush. 

But the most necessary and essential point in the treat- 
ment of all excisions is good hygienic influences ; and of 



166 EXCISION OF THE KNEE-JOINT. 

these pure air is the most important. A part of the suc- 
cess attending the operations performed in London may be 
attributed to the Hospital for Convalescents at Margate, to 
which the reports show that many of the patients were sent 
from the Metropolitan institutions. " Nothing like union 
took place," says one operator, " until the patient was re- 
moved to the sea-side, when he rapidly improved, and came 
back with a very fair leg." Mr. Fergusson writes : " One 
of my dressers, who has just been down to Portsmouth, has 
seen one of my cases, a little girl on whom I operated four 
or five months since. She made an excellent recovery, but 
at the end of four or five months there did not seem the 
least disposition to the formation of bone. The change of 
air, however, has been most beneficial, and now the leg is 
firm, and she walks actively about without any assist- 
ance." 

The length of time required for the cure of excision of 
the knee is one of the most serious objections to the opera- 
tion. Whilst, as an extraordinary and altogether excep- 
tional thing, the patient may be upon crutches in six weeks 
from the time of the operation, with the wound united and 
a safe amount of consolidation between the bones, and in 
six months walk more nimbly than he could have done 
with an artificial limb, it is oftener the case that months 
elapse before the crutches are reached, and many months 
more before they are abandoned, even for a cane. A still 
more discouraging picture than this is drawn by Mr. Bar- 
well, who says : " In what proportion of cases which are 
returned as with perfect use of the limb, after excision of 
the knee-joint, a valuable member is retained, it is impossi- 
ble to say ; but that we must not suppose all such limbs to 
remain useful, I know from having seen two or three men 
in different institutions, who, as they walked about, and at 
last out of the hospital perfectly well, justified the report 
of * perfectly sound limb,' yet who, at various periods, have 
returned under care with some defect. The union perhaps 
yields, and the limb, bending outwards more and more, be- 



OPERATION AND AFTER-TREATMENT. 167 

comes less and less available ; or the man will have gone 
away with a sinus open : it is justly said, that such sinuses 
often do remain open for months, and then heal, but some- 
times they do not heal, and then a year or two afterwards 
dead bone will be found, which will require removal." 1 
For one patient who, like Mr. Heusser's, in nine months 
after the operation walks up a mountain 6,500 feet high, 
and every winter keeps his surgeon supplied with chamois 
meat and Alpine birds of his own killing, two are found 
like Mr. Hancock's, operated on in 1858, recovering in five 
months, and going to work as a gardener ; but, after re- 
peated attacks of pain, which would send him to bed for a 
longer or shorter time, re-entering the hospital, May 5th, 
1860, undergoing a second severe operation, and on De- 
cember 14th — seven months afterwards — reported to be 
" going on well, and promises to recover soundly." For- 
mal re-excision has even been found necessary. A young 
woman, whose knee-joint had been excised, and who, when 
she was able to walk across the room with support, was 
discharged from the hospital as cured, came under the care 
of Mr. Fergusson, ten months after the operation, with a 
partial dislocation of the tibia backwards, sinuses, fistulae, 
and ulceration of the integument. Mr. Fergusson deter- 
mined to re-excise the bones, which he did by cutting off 
one inch of the femur and the upper end of the tibia. At 
the end of five and a half months she was again discharged 
with firm union and a straight limb, but with five inches' 
shortening, and a future history of which we know noth- 
ing. 2 A similar course, with a fatal result, was pursued 
by Heusser, in 1852, for non-union after a resection per- 
formed twenty weeks previously. 3 

The extremes of " time under treatment" in my table 
are 27 months, and 7 weeks : and it appears, from 80 cases 
in which it is recorded, that the average duration of treat- 

1 Tr. on Dis. of the Joints, p. 453. 2 Lancet, May 18, 1861. 

3 O. Heyfelder, op. cit., p. 118, Case 50. 



168 EXCISION OF THE KNEE-JOINT. 

ment was 241 days, or about 8 months. According to Mr. 
Sansom, the average time required for recovery from am- 
putation of the thigh, for diseased bone, is 48 days. 1 



DISSECTIONS. 



As has been already said, nothing of special importance, 
in connection with the results of this operation, is eluci- 
dated by the dissection of the parts involved, long after the 
excision has been performed. It simply shows the facts, 
that the early union is fibrous, and that the osseous union, 
which takes place later, begins first around the periphery 
of the bones. In cases where the leg swings on the thigh, 
and requires amputation on account of its uselessness, it is 
generally found that the ends of the bones are more or less 
absorbed ; the union between them being by bands, stretch- 
ing from the cut surfaces, and not from the sides. The 
general nutrition of the limb, wasted by long disease, is 
rarely regained, and its size is almost always dispropor- 
tionate to that of its fellow, even after a long lapse of time. 
Many of the muscles, too, being deprived of their useful- 
ness, undergo fatty degeneration ; this is especially the 
case with those of the thigh. 

1 The Mortality after Operations of Amputation of the Extremities, (Lond. 
1859,) p. 19. 



CONCLUSIONS. 169 



CONCLUSIONS. 



The preceding pages authorize the following conclu- 
sions : — 

First, That although excision of the knee-joint was 
performed by Mr. Filkin, of Northwich, England, in 1762, 
Mr. Park, of Liverpool, in 1781, first reported a case, and 
suggested the feasibility of such an operation. 

Second, That the small degree of success following 
the few cases of excision performed for traumatic cause 
does not warrant inferences favorable to its future adop- 
tion as a substitute for amputation. 

Third, That excision for anchylosis is followed by such 
a mortality as to discourage its repetition, especially when 
the results of orthopedic treatment are remembered, and 
the fact that a crooked limb is not necessarily useless, nor 
absolutely a hindrance to self-support. 

Fourth, That excision for "white swelling" is followed 
by a mortality greater than that of amputation for the 
same cause, — one death occurring in every 3 T 7 5 opera- 
tions. Therefore, although occasionally yielding brilliant 
results, it is an operation to be practised with great reserve. 

Fifth, That partial operations upon the knee, as in other 
ginglymoid joints, add materially to the number of unfa- 
vorable cases. As non-removal of the patella converts the 
excision into a partial one, this bone should never be 
allowed to remain. 

Sixth, That, in young patients, excision beyond the line 
of junction between the epiphysis and the shaft of the bone 
is liable to lead to an arrest of growth in the limb operated 
upon. 



15 



170 . EXCISION OF THE ANKLE-JOINT. 



ANKLE-JOINT 



HISTORY. 

" Mr. Cooper, of Bungay, many years ago, sawed off 
both the head of the tibia and fibula in a compound luxation 
(of the ankle), by which means he preserved the limb, and 
made it so useful, that the poor man walks and works for 
his bread ; of which success I am a witness." Mr. Benja- 
min Gooch, 1 of Norwich, England, in 1758, thus alludes to 
what is undoubtedly the first recorded case of excision of 
the ankle-joint, although the operation was a partial one. 

According to Wachter, many instances in which two or 
three, and even four, inches of the ends of the tibia and 
fibula were removed, after injuries, were related by Bil- 
guer in 1781. 2 

In 1792, the ends of the tibia and fibula were excised 
by Moreau, with success, nineteen days after the accident 
of a compound dislocation. 3 

In 1805, Henry Park speaks of a case where the end of 
the tibia was excised for a compound dislocation, with a 
most satisfactory result ; 4 and Mr. Hey, of Leeds, also says, 
that, in 1805, Mr. Taylor, a surgeon of Wakefield, showed 
him five specimens of the lower extremity of the tibia, 
which he had sawed off after compound dislocations. 5 

The first excision of this joint for disease was by the 
elder Moreau, April 15, 1792 ; the patient walked, without 
halting, at the end of nine months, and his limb was ad- 

1 Cases and Practical Remarks in Surgery, 1st ed. (Lond. 1758.) 

2 De Artie. Extirp., p. 29. 

3 Malgaigne, Traite des Luxations, (Paris, 1855,) p. 215. Cited from the 
younger Moreau's Essay. 

4 Jeffray's Park and Moreau, p. 70. 

5 Practical Observations in Surgery, (1810,) p. 381. 



HISTORY. 171 

mired by Baron Dubois. It was next performed in 1796, 
by the younger Moreau, and the patient, though he walked 
very badly, partly, perhaps, because he ran away from the 
hospital at the end of six months, still got along without 
crutches. 1 

It does not appear, however, that, after the above cases, 
this operation was again attempted for disease, until 1818, 
when it was undertaken by Mr. Liston, in Edinburgh. 2 In 
April, 1830, it was performed in France by M. L. Cham- 
pion, 3 and in June of the same year by M. Roux. 4 Decem- 
ber 27, 1847, Mr. Thomas Wakley, of London, excised the 
os calcis and astragalus, 5 and in March, 1850, the end of 
the fibula, together with part of the astragalus. 6 It ap- 
pears, therefore, that the honor of first performing this 
operation in Great Britain belongs to Mr. Liston ; and of 
re-introducing it, to Mr. Wakley, rather than to Mr. Han- 
cock, for whose excision of February 17, 1851, it has 
been claimed. 7 

The only instances of the performance of this operation 
in the United States, so far as I am aware, are an excision 
of the astragalus for disease, by Dr. Peace, of the Pennsyl- 
vania Hospital, in March, 1853, 8 and of the astragalus and 
os calcis by Dr. S. Cabot, of Boston, September 3, 1859. 9 
The successful removal of the astragalus by Dr. Wells, of 
Columbia, Georgia, in 1831, six months after an injury, 10 
although said to have been performed for caries, was more 
probably for necrosis ; and there is reason to suppose that 
under similar circumstances such an operation has been 
practised many times by others. 

1 Jeffray's Park and Moreau, pp. 140, 146. 

2 Edinb. Med. and Surg. Journ., Jan. 1821, p. 155. 

3 Blackman's Velpeau, Vol. II. p. 487. 

4 Gaz. Hebdom. de Med., Tom. VIII. p. 214. 

5 Lancet, April 12, 1851. 

6 Ibid., May 25, 1850. 
' Ibid., Oct. 1, 1859. 

8 Gross. Syst. of Surg., (Philad. 1859,) Vol. II. p. 1093. 

9 Records of Bost. Soc. for Med. Imp., Vol. IV. p. 65. 
10 Am. Journ. of Med. Sc, Vol. X. (1832,) p. 21. 



172 EXCISION OF THE ANKLE-JOINT. 

The destruction of the articulation of the ankle by re- 
moving the entire astragalus, in cases of dislocation of that 
bone, appears to have been resorted to as early as the six- 
teenth century. 1 M. Roux, in his Relation d'un Voyage d 
Londres en 1814, (p. 209,) after complimenting the surgery 
of Mr. Hey, of Leeds, who excised the astragalus under 
these circumstances as early as 1786, 2 says : " Nous pouvons 
bien parler des cas dans lesquels, — a 1' example de Fabrice 
d'Hilden, — Ferrand, Dessault, L'Aumonier, et plusieurs 
autres chirurgiens Frangais, ont extrait completement l'as- 
tragale dans les luxations compliquees de Tissue de l'os a 
travers une plaie de 1' articulation." Advocated in a very 
emphatic manner by Sir Astley Cooper 3 and others, this 
exsection may be considered as an established operation in 
surgery. 

The ankle-joint has been excised in cases of compound 
dislocation, and for disease ; and I have just alluded to the 
frequency with which exsection of the astragalus has been 
performed in cases of dislocation, without removing any 
other parts of the articulation. 



EXCISION FOR INJURY. 

Excision of the ends of the tibia and fibula is spoken 
of by all authors in connection with the management 
of certain compound dislocations of the ankle-joint ; viz. 
those which cannot be reduced, or, if reduced, kept in 
position, — the laceration not being too extensive, or the 
contusion such as to threaten sloughing, and when com- 

1 Fabritius Hildanus, Obs. Chirurg., (Frankfurt A. M., 1682,) Centur. II. 
Obs. 67. 

2 Pr. Obs. in Surg., p. 386. 

3 Tr. on Disloc. and Fract., (Am. ed.,) p. 287, et seq. 



EXCISION FOR INJURY. 173 

minution of the other tarsal bones is not an added compli- 
cation. The case related by Faure, of a soldier at the bat- 
tle of Fontenoy, wounded in the ankle-joint by a " bis- 
caien," where the ends of the tibia and fibula, together 
with the astragalus and portions of the other tarsal bones, 
were removed, can only be regarded as an instance of 
expectant surgery, as amputation was performed on the 
forty-seventh day after the accident. 1 The os calcis and 
part of the astragalus were also removed once with suc- 
cess, in the Crimea, for a gun-shot injury. 2 

In speaking of the application of excision to the cases of 
dislocation above mentioned, Sir Astley Cooper declares, 
that he has " known no case of death when the extremities 
of the bones have been sawed off, although he shall have oc- 
casion to mention some cases which terminated fatally when 
this was not done." 3 Malgaigne expresses the opinion, that 
excision is a less dangerous operation than either simple re- 
duction or amputation, and should be performed according 
to the exigencies of each case, but not as a general rule. 
He alludes to a case of dislocation, where, on the fifth day, 
there was a general spasm, resembling tetanus, loss of con- 
sciousness, an almost imperceptible pulse, and a hopeless 
general condition. The surgeon in charge excised an inch 
and a half of the tibia, and replaced the bones. The pulse 
came up the same evening; consciousness returned, and 
recovery eventually took place. 4 

A remarkable instance is quoted by Vidal, of a young 
girl who had been buried underneath a slide of earth, by 
which her feet were turned backwards against the calves 
of her legs ; the tibia and fibula of one side, and the tibia 
alone of the other, were protruded, the articular cartilages 
wounded, and the periosteum torn up. Two inches of the 
right tibia, and an inch and a half of the left tibia and fibula, 

i Prix de l'Acad. de Chir., Tom. III. p 340. 

2 Med. and Surg. Hist, of the Brit. Army which served in Turkey and the 
Crimea, Vol.11, p. 368. 

3 Disloc. and Fract., (Am. ed.,) p. 251. 

4 Tr. des Fract. et des Lux., Tom. II. (1855,) pp. 1004, 1025. 

15* 



174 EXCISION OF THE ANKLE-JOINT. 

were excised. Three months afterwards the girl walked 
with a cane ; and this she gave up at the end of another 
month, although some limping still remained. 1 

Mr. Jones, of Jersey, excised the ends of the tibia and 
fibula, and the surface of the astragalus, twenty-two days 
after a compound dislocation with fracture of the malleoli, 
on account of the profuse suppuration, death of the bones, 
and constitutional disturbance ensuing. The operation was 
performed on the 18th of April, and on the 23d of July the 
patient, having for ten days been able to walk some dis- 
tance without support, ran away from the hospital, and 
walked five miles with the aid of a stick and a crutch. 2 A 
similar operation for a similar condition of the parts, five 
months after an injury (whether fracture or dislocation 
was not clear), was performed by C. W. Klose, in 1854. 
The patient was sixty years of age, and at the end of ten 
weeks was able to walk out with a crutch. 3 

In 29 cases of excision of the ankle for injury, reported 
in the tables of Jaeger, only a single death is said to have 
occurred. 4 Malgaigne speaks of the uniform success char- 
acterizing the five operations of Taylor, the six of Josse, 
and the nine of Astley Cooper. 5 And Mr. Kerr, writ- 
ing to the last-named surgeon, in 1819, says : " Several 
cases of compound dislocation have fallen under my care, 
and it has been uniformly my practice to take off the lower 

extremity of the tibia In my early life, sixty 

years ago, I saw many attempts to reduce compound dis- 
locations, without removing any part of the tibia ; but, to 
the best of my recollection, they all ended unfavorably, or 
at least in amputation. By the method which I have pur- 
sued, I have generally succeeded in saving the foot." 6 

It is noticeable that this excision, which is always a par- 

i Tr. de Path. Ext., (Paris, 3 me ed., 1851,) Tom. V. p. 568. 

2 Med. Times and Gaz., Jan. 6, 1855. 

8 H. J. Paul, Die Conservative Chirurgie der Glieder, (Breslau, 1859,) p. 206. 

4 Op. cit., p. 9. 

6 Op. cit., Vol. II. p. 1025. 

• Cooper, Fract. and Disloc., (Am. ed.,) p. 249. 



EXCISION FOR INJURY. 175 

tial one, is not subject to the unfortunate accidents usually 
characterizing such operations elsewhere ; leaving the artic- 
ular surface of the astragalus does not seem to retard or 
complicate the progress of the case, as might be feared. 

The operation is usually followed by anchylosis ; but in 
several cases, reported by Astley Cooper, motion was pre- 
served. 

Looking at the results of amputation of the leg for trau- 
matic cause, — which show, taking the experience of Guy's 
Hospital, a mortality of 62.5 per cent in primary, and 
66.66 per cent in secondary operations, 1 whilst, according 
to Mr. Syme, 11 deaths (65 per cent) followed 13 amputa- 
tions for compound dislocation of the tibia and fibula, per- 
formed in the Royal Infirmary of Edinburgh, 2 — conclusions 
favorable to excision seem fully warranted. 

The propriety of removing the astragalus, in cases of its 
irreducible and double dislocation, from the bones of the 
leg on one side, and from the os calcis and os scaphoides on 
the other, seems to be considered a settled point by most 
surgical writers. 

M. Paul Broca, a well-known French surgeon, from an 
analysis of 160 dislocations of the astragalus, concludes 
that, — 

1st. " In dislocations unaccompanied by a wound, we 
must attempt reduction. If our attempt fails, we must 
wait. In the event of an abscess occurring afterwards, we 
must open it, and subsequently extract the astragalus, — 
an operation which is then attended by remarkably little 
danger." 

2d. " In dislocations where there is a wound, we must 
also attempt reduction, having recourse to debridement 
and tenotomy if necessary. When reduction is not pos- 
sible, the astragalus should be at once removed, as by 
this operation three fourths of the patients are saved. It 

i Med.-Chir. Trans., Vol. XLII. p. 71. 
2 Edinb. Monthly Med. Journ., Aug. 1844. 



176 EXCISION OF THE ANKLE-JOINT. 

is less grave than amputation of the leg, and has the ad- 
vantage of preserving the functions of the limb." 1 

"Compound dislocations (of the astragalus), and such 
as are otherwise complicated," says Dr. Hamilton, " de- 
mand of the surgeon immediate amputation or exsection, 
the latter of which ought to be preferred whenever the 
condition of the limb encourages a reasonable hope that 
the foot may be saved." 2 

Mr. Turner, of Manchester, in a voluminous memoir, 3 
from an analysis of 46 cases, arrives at conclusions almost 
identical with those of M. Broca. But it would seem, 
from an article in the British and Foreign Medico-Chi- 
rurgical B,eview, (July, 1844, p. 124, and October, 1844, 
p. 565,') that his cases are very imperfectly and some- 
times inaccurately reported. It appears from his table, 
that in 10 cases where the bone was allowed to remain 
in its new locality, and in 6 of complete reduction, 2 of 
partial reduction, and 6 of partial excision, recovery took 
place in all, with more or less permanent lameness. In 
18 cases of complete excision there were 14 recoveries (of 
course with permanent lameness), and 4 deaths. In 4 dis- 
locations the limb was amputated. According to this ta- 
ble, then, the only deaths were after excisions. 

The table of Jaeger comprises 27 cases of excision of 
the astragalus for dislocation, with only one fatal and one 
doubtful result. 4 

Mr. Jolliffe Tuffnell, Regius Professor of Military Sur- 
gery in Trinity College, Dublin, referring to the memoir 
of Mr. Turner, expresses, in the following words, what 
may undoubtedly be accepted as a true estimate of this 
operation. " I am myself," he says, " an advocate of con- 
servative surgery, so far as the objects to be derived from 
it are real gains and undoubted advantages to the indi- 

1 Mem. de la Soc. de Chir. de Paris, Tom. II. p. 570. 

2 Pr. Tr. on Fract. and Disloc., p. 702. 

3 Trans, of the Provincial Med. and Surg. Assoc, Vol. XI. pp. 367 - 502. 

4 Op. at., p. 25. 



EXCISION FOR DISEASE. 177 

vidual ; but it may be overdone, as I am convinced it 
often is in the cases here before us. I am speaking now 
from the experience of three cases which have come under 
my own observation, in each of which the bone was re- 
moved at different periods after the receipt of the injury, 
and in each of which the individual gained what would, 
I am convinced, be reported as a useful foot ; but in nei- 
ther of these three cases can the individual gain his 
bread." 1 

Anchylosis usually, but not invariably, follows the ab- 
straction of the astragalus, together with a shortening of 
about an inch. In a case reported in an article on the 
subject by MM. Rognetta and Deschamps, where the for- 
mer excised this bone from a patient wounded at the ter- 
rible accident on the Versailles Railroad, in May, 1842, 
there was absolutely no shortening. The quarrels of the 
doctors over the patient make the fact a well-authenti- 
cated one. 2 



EXCISION FOR DISEASE. 

According to Mr. Bryant, disease of the ankle-joint oc- 
curs with a frequency of about one to four of disease of 
the hip and knee, in which it is nearly equal and most 
common. 3 

The extreme difficulty of diagnosticating the precise seat 
of disease situated in or near the ankle-joint, the insidious 
manner in which it travels from one bone and articulation 
to others near it, and the difficulty of exposing the articu- 
lation when the bones are in their normal positions, are 
discouraging circumstances in connection with the perform- 

1 Dublin Med. Press, Dec. 28, 1853. 

2 Cited in Lond. and Edinb. Monthly Journ. of Med. Sc, Aug. 1843. 

3 Dis. and Inj. of Joints, p. 136. 



178 EXCISION OF THE ANKLE-JOINT. 

ance of excision for caries and articular disease, however 
well adapted it may be thought for injuries and disloca- 
tions, where the amount of lesion is easily ascertained, and 
the protrusion of the bones renders the removal of their 
extremities a comparatively easy matter. It is to be borne 
in mind, also, how much may be, and generally is, com- 
prised in the term " carious disease of the ankle-joint,' ' and 
that under it may be included a state of things implicating 
nearly every one of the tarsal bones. 

The history of the operations which have been performed 
shows, too, how varying is the extent to which excision has 
been carried by the requirements of a disease, the centre 
of which was the tibio-tarsal articulation. Whenever more 
than the surfaces of this joint are diseased, and the removal 
of the whole astragalus, with perhaps a portion of some 
other bone, is required, the operation becomes a partial 
one, — like those already spoken of in connection with the 
wrist-joint (p. 78), — and one in which the most important 
condition of successful excision is not fulfilled. The foot 
is even worse, in this respect, than the hand, since it is 
usually the bones, and not the articulations, which are pri- 
marily diseased ; these, from their cancellous and vascular 
structure, from their distance from the centre of circula- 
tion and exposure to variations of temperature, readily be- 
come carious ; whilst the articulations, remaining healthy, 
are just in the condition to propagate inflammation, if 
opened and subjected to its exciting causes. 

It must, however, be admitted, that in more cases than 
might have been anticipated excision of the ankle-joint has 
resulted in success. Three of Mr. Hancock's four cases 
were certainly all which could be desired, and justify, per- 
haps, the remarks he makes upon his own experience, that 
" in no instance has there been sloughing ; there need 
not be a single tendon divided ; there is afterwards very 
little if any deformity, and comparatively little shortening ; 
the foot is preserved ; and, as you will see by the cases I 
here relate, the patients are able to walk and run about 



EXCISION FOR DISEASE. 179 

with scarcely any perceptible limp." 1 Of five operations 
for disease, recorded by Jaeger, four were successful, and 
ill one the result was doubtful. 2 

The reports of cases in which this operation has been 
performed, demand, I believe, more distrust than any other 
excision. The insidious manner in which disease of the 
tarsus works its way about the foot ; the unexpected out- 
breaks which it constantly makes on the slightest provoca- 
tion, or without any ; the great length of time ordinarily 
required for its cure ; and, above all, the variety in opinion 
as to what constitutes a " useful limb," or what " walking 
without a limp " means, as well as the precipitate manner 
in which cases are reported, are all considerations which 
render the deductions from any table uncertain and unsat- 
isfactory. For instance, conclusions derived from a case 
like that reported in the Lancet of December 15th, 1855, 
as " followed by complete success," are set at naught by 
subsequent statements in the Lancet of January 9th, 1858, 
and October 1st, 1859, from which it appears that the oper- 
ation " was not successful, though it promised well at the 
time," the patient dying six or seven months afterwards. 

The results, therefore, to be derived from the following 
table are to be taken as presenting even more than the 
brightest aspect of the question. It includes every instance 
of which I can obtain information, where the integrity of 
the diseased tibio-tarsal articulation has been interfered 
with, and comprises operations varying in extent from the 
removal of a single surface to the exsection of several 
tarsal bones. Such cases are not, however, improperly 
classed together ; they illustrate the application of the op- 
eration to the different conditions of ankle-joint disease, 
and the fact that the uncertainties of diagnosis prevent 
its restriction to any precise or prescribed amount of 
morbid change. 

1 Lancet, Oct. 1, 1859. 2 Op. cit., p. 9. 



180 



EXCISION OF THE ANKLE-JOINT. 



No. 


Authority. 


Sex. 


Age. 


Termination. 


Time under 
Treatment. 


1 


Lancet, April 9, 1859. 


M. 


6 


Recovery. 


5 mos. 


2 


Med. Times and Gaz., May 8, 1857. 


M. 


31 


(t 


7 mos. 


3 


Med.-Chir. Trans., Vol. XXXVII. 

p. 1. 
Lancet, Nov. 12, 1853. 


M. 


5 


it 


10 mos. 


4 


M. 


15 


(t 


16 mos. 


5 


Jeffray's Park and Moreau, p. 140. 


M. 




« 


9 mos. 


6 


Ibid., p. 146. 


M. 


17 


a 


6 weeks. 


7 
8 


J. F. Heyfelder, Ueber Resect, und 

Amp., p. 169. 
Med.-Chir. Rev., Oct. 1857. 


M. 


35 


Amp. Died. 
Recovery. 


10 weeks. 


9 
10 


Gross. Syst. of Surg.,Vol. II. p. 1093. 
Med. Times and Gaz., July 30, 1859. 


M. 
M. 


11 
26 


Recovery. 
Amputated. 


6 mos. 
3 years. 


11 


Ibid., Oct. 17, 1857. 


M. 


42 


Died. 


4 days. 


12 


Ibid., Jan. 16, 1858. 


M. 


8 


Recovery. 


15 mos. 


13 


Ibid. 


M. 


15 


Amputated. 


10 weeks. 


14 


Ibid., Aug. 7, 1858. 


M. 


26 


ft 


4^ mos. 


15 

16 
17 

18 


Lancet, Aug. 25, 1855. Statham's 

Stromeyer and Esmarch, p. 118. 
Lancet, Oct. 1,1859. 
Med. Times and Gaz., Feb. 24, 1855. 
Ibid., June 16, 1855. 


M. 

F. 
M. 
M. 


43 
22 
30 


Recovering. 

Died. 

Recovery. 

Recovering. 


8 mos. 

7 mos. 

10 weeks. 


19 

20 
21 


Lancet, Mar. 29, 1851, and Oct. 1, 

1859. 
Ibid., Nov. 12, 1853. 
Ibid., April 12, 1851. 


M. 

M. 
M. 


8 

52 
23 


Recovery. 

Amputated. 
Recovery. 


3 years. 

22 days. 
7 mos. 


22 


Ibid., May 25, 1850. 


F. 


23 


Recovering. 


7 weeks. 


23 


Med. Times and Gaz., Nov. 14, 1857. 


M. 


2 


Recovery. 


7 mos. 


24 


Ibid., Jan. 9, 1858, and Oct. 1, 1859. 


M. 


25 


(t 


3 mos. 


25 


Glasgow Med. Journ., Vol. II., 1855, 

p. 1. 
Med. Times and Gaz., Nov. 20, 1858. 


F. 


18 


Died. 


6 weeks. 


26 


F. 


25 


Recovering. 


1 month. 


27 


Lancet, June 18, 1859. 


M. 




Recovery. 


6 mos. 


28 


Mass. Gen. Hosp. Records. 


M. 


36 


Amputated. 


4 mos. 



EXCISION FOR DISEASE. 



181 



Extent of Removal. 



End of tibia and portions of astragalus 

and os calcis. 
Ends of tibia and fibula ; surface of 

astragalus. 
Astragalus and part of os calcis. 

Ends of tibia and fibula ; surface of as 
tragalus in both feet. Subsequent 
removal of part of os calcis on both 
sides. 

Ends of tibia and fibula ; surface of as- 
tragalus. 

End of tibia. 

Ends of tibia and fibula ; parts of as- 
tragalus and os scaphoides. 
" Ankle-joint and one or more bones of 

tarsus." 
Entire astragalus. 
Ends of tibia and fibula and surface of 

astragalus. 
Ends of tibia and fibula ; surface of as 

tragalus. 
End of fibula; part of tibia; whole of 

astragalus ; part of os calcis. 2d op 

eration at end of 5 months. 
Ends of tibia and fibula ; whole of as 

tragalus ; part of cuboid bone. 

Ends of tibia and fibula ; surface of as 
tragalus. 

Whole of astragalus. Later, ends of 
tibia and fibula. 

End of tibia ; surface of astragalus. 

End of tibia ; whole of astragalus. 

Ends of tibia and fibula ; whole of as- 
tragalus ; part of os calcis ; 3 cunei-j 
form bones. 

Ends of tibia and fibula ; surface of 
astragalus. 

End of tibia ; surface of astragalus. 

Ends of tibia and fibula ; os calcis and 
astragalus. 

End of fibula ; surface of astragalus. 

Entire astragalus. 

Ends of tibia and fibula and astragalus. 

Ends of tibia and fibula and astragalus. 

End of tibia ; surface of astragalus. 

Ends of tibia and fibula, astragalus, and 

part of os calcis. 
End of fibula; astragalus and os calcis 



16 



Remarks. 



Walks without pain. Left leg. 
Parts healed, but limb still weak. 

Complete mobility ; walks and runs 

without pain. Left leg. 
Both feet quite sound. Walks well 

with aid of a stick. 

Walks without halting. Left leg. 

Walks badly, but without crutches. 

Left leg. 
Amputation from exhaustion. Death 

from pyaemia in 7 days. Left leg. 
Walked eventually with a stick. 

Wounds healed, and some motion. 
Amputated at patient's request, hav- 
ing never used the limb. 
Death from exhaustion. 

Tolerable result claimed, but the de- 
scription is not at all satisfactory. 
Right leg. 

Amputated on account of abscesses 
and*" infiltrating disease." Recov- 
ered. Left leg. 

Amputated for disease of soft parts. 
Recovery. Left leg. 

Left leg. 

Death from phthisis. 

Anchylosis, but useful limb. R. leg. 

Considerable firmness ; able to move 
foot without support ; some dis- 
charge. Right leg. 

Walks with hardly any limping. Con- 
siderable motion in joint. Left leg. 

Amputation for exhaustion. Recov. 

Walks well with a high-heeled shoe. 
Left leg. 

Left hospital in a very satisfactory 
state. Right leg. 

Walks well with an iron support. 
Left leg. 

Two years after operation walks re- 
markably well. 

Death from phthisis. 

Wound nearly healed. Ankle mova- 
ble without pain. Right leg. 

Useful and strong foot ; movable ar- 
ticulation. Right leg. 

Amputation for returning disease. 
Recovery. Right leg. 



182 



EXCISION OF THE ANKLE-JOINT. 



No. 
29 


Authority. 


Sex. 


Age. 


Termination. 


Time under 
Treatment. 


Lancet, Oct. 1, 1859. 


M. 


6 


Recovery. 


6 mos. 


30 


Med. Times and Gaz., Mar. 30, 1860. 


F. 


10 


<« 


1 year. 


31 


Edinb. Med. and Surg. Journ., Jan. 
1821. 


F. 


12 


« 




32 


Journ. Hebdom. de Med., Vol. VIII. 
p. 214. 


M. 


16 


« 




33 


Jaeger, Op. Resect., p. 26. 










34 


Lancet, Oct. 1, 1859. 






tt 




35 


Blackman's Velpeau, Vol. II. p. 487. 


M. 




<< 




36 


Ibid. 


F. 




«« 




37 


Ibid. 






Died. 




38 


Statham's Stromeyer and Esmarch, 
p. 117. 


F. 


5 


Recovery. 


18 mos. 


39 


Path. Cat. of Mus. of Guy's Hosp., 
p. 192. 






Amputated. 


7 mos. 


40 


0. Heyfelder's Operationslehre, p. 
163, No. 12. 






u 


1 year. 


41 


Ibid., No. 18. 


M. 


23 


Recovery. 




42 


Ibid., No. 11. 


M. 




tt 




43 


Ibid., No. 16. 






Died. 




44 


Ibid., No. 17. 


M. 


H 


Recovery. 


4 mos. 


45 


Ibid., p. 173. 


M. 


17 


Amputated. 


24 days. 


46 


Med. Times and Gaz., Apr. 27, 1861. 


M. 


12 


" 


8| weeks. 


47 


Ibid. 


F. 


26 


Unsatisfact'y. 




48 


Ibid., Aug. 10, 1861. 


M. 




Recovery. 


4 mos. 



The preceding table enumerates 48 cases, in 32 of which 
the patients were males, and in 9 females ; in 7 the sex is 
not stated. In 8 the excision was of the right, and in 12 
of the left ankle ; in 1 both ankles were excised, and in 
the remaining 27 the side is not mentioned. 

Of these 48 cases, 27 resulted in recovery ; in 10, sub- 
sequent amputation was performed, of which one died ; 
and in 5, the primary operation proved fatal. In 6 cases 
the treatment was not completed. Of the 15 cases which 
proved fatal, or where the patient underwent amputation, 
the side is stated in 4 only, viz. 3 of the left, and one of the 
right. 

In the 5 fatal cases death was caused by phthisis in 3, 
pyaemia in one, and in one the cause is not mentioned : it 
occurred at the end of 7 months, 6 weeks, and 4 days, re- 
spectively, — the time not being recorded in one instance. 



EXCISION FOR DISEASE. 



183 



Extent of Removal. 


Remarks. 


End of tibia, astragalus, part of os calcis. 
End of fibula and astragalus. 

End of tibia, astragalus, scaphoid and 2 
cuneiform bones. 

Ends of tibia and fibula ; surface of as- 
tragalus. 

Astragalus and os scaphoides. 

Os calcis, astragalus, and cuboid bone. 

Not stated. 

Not stated. 

Not stated. 

Ends of tibia and fibula and astragalus. 

End of tibia and astragalus. 

Ends of tibia and fibula and astragalus. 

Ends of tibia and fibula, astragalus, part 

of os calcis and scaphoid. 
Ends of tibia and fibula and astragalus. 
Ends of tibia and fibula and astragalus. 
Ends of tibia and fibula and astragalus. 
Astragalus and os calcis. 
Ends of tibia and fibula. Astragalus 

and os scaphoides. 
Ends of tibia and fibula and astragalus. 
Ends of tibia and fibula and astragalus. 


Walks without pain. Left leg. 

Foot distorted by contraction of ten- 
dons. 

" Lasting cure without much deform- 
ity or lameness." 

Useful limb. 

Doubtful result. 
No details. 

" Uses his foot very advantageously." 
Repeatedly walked 3 miles to show 
herself. 

Walks with iron supports. Right leg. 

" Never quite healed." 

Recovery. 

Movable articulation and little short- 
ening. 
Movable joint. 
Phthisis. 
Movable joint. 
Recovery. 
Recovery. 

"Does not support body in a very 
satisfactory manner." 



In the 10 cases of amputation, that operation was demand- 
ed, on account of exhaustion, for returning disease either 
of the soft parts or of the bones, and for uselessness in the 
resulting limb. 

There appears to be nothing, however, to distinguish 
either the operation, or the cases which thus failed, from 
those which proved successful, except the ages of the pa- 
tients. These range from 2 to 52 years. The average age 
of those recovering is 12 T 9 cr years ; that of the cases which 
proved fatal, and of those in which amputation was per- 
formed, 27 T 4 T years. 

The successful operations vary in the extent to which 
bone was removed, from simple excision of the end of the 
tibia, to that of the end of the tibia and fibula, with the 
whole of the astragalus and parts of the calcaneum and 
three cuneiform bones. The extent of removal does not 



/ 



/ 



184 EXCISION OF THE ANKLE-JOINT. 

appear to have much influenced the result ; for of the 
33 patients who recovered, or who were under treatment, 
really useful limbs were regained in 22 ; in 5 the result 
was not satisfactory ; in 5 the patients were doing well ; 
and in one the issue was doubtful. 

A very considerable degree of mobility in the new joint, 
and a very useful limb, free from deformity or much lame- 
ness, seem to have characterized some of the successful 
cases. The first one operated on by Moreau is described 
by Percy in the following words : " There was no tibio- 
tarsal articulation, but the astragalus with the scaphoid, 
and the calcaneum with the cuboid, had acquired such a 
mobility, that they supplied perfectly the place of the lost 
joint, and the patient, who wore a high-heeled boot, walked 
with a very slight limp." 1 Mr. Hancock speaks of one of 
his patients as " walking, running, and jumping " ; and 
says of another, that " he met him the other day, walking 
down Hampstead Hill, and he certainly showed no signs of 
having undergone so serious an operation." 2 

Summing up these statements, we have then 6 deaths, — 
one being after amputation, — or a mortality of 12.50 per 
cent ; 10 amputations ; 5 failures ; and one case in which 
the result was very unpromising. Of 48 cases, therefore, 
in 21 the object of the operation was not attained ; or, in 
other words, there was a failure in 43.75 per cent. Ac- 
cording to Mr. Bryant, in 39 amputations of the leg for 
disease, there is only a mortality of 1 in 13, or 7.7 per 
cent. 3 

These figures certainly add force to the remarks of the 
Medical Times and Gazette of July 30th, 1859, and which 
— speaking of one of the cases contained in the preceding 
table, where the limb was amputated, at the patient's re- 
quest, three years after the original operation, he never 
having been able to use it — says, that it is only " too good 

1 Diet, des Sc. Med., Vol. XL VII., Art. Resection. 

2 Laneet, Oct. 1, 1859. 

3 Med.-Chir. Trans., Vol. XLII. p. 71. 



OPERATION AND AFTER-TREATMENT. 185 

an example of the usual result after excision of the ankle- 
joint. For the wrist and ankle, where many bones have to 
be interfered with, the operation of excision seems but ill 
adapted. We have seen some good results, but we have 
seen better after treatment by rest and constitutional meas- 
ures only. The surgeon's knife, and, above all, his gouge, 
are but too liable to extend the carious ulceration which 
they are intended to remove. Cases of this class repeat- 
edly disappoint an infinity of care and trouble, and come to 
amputation at last." 



OPERATION AND AFTER-TREATMENT. 

The operation of excising the ankle-joint is, as has been 
said, one of considerable difficulty. The necessity of pre- 
serving the tendons, as well as the anterior and posterior 
tibial arteries, and the peculiar tenon-and-mortise charac- 
ter of the joint, render the excision one of no easy execu- 
tion, unless the disease has so glued the tendons together, 
cut off the arteries, destroyed the ligaments, and separated 
the bones, that incisions may be made into the disinte- 
grated and fused tissues, at any point, and the bones easily 
dislocated and made accessible. 

The method of operating usually adopted is that of Mr. 
Guthrie. A curved incision, commencing behind the outer 
malleolus, and some distance above its tip, is carried around 
the extremity of that bone, and then forward and across 
the front of the foot to the internal malleolus. This in- 
cision divides only the integument. The peroneal tendons 
are next loosened and carried to one side. The lateral 
ligaments, holding the outer malleolus, being cut, the end 
of the fibula is removed with the bone-forceps. The di- 
vision of the internal lateral ligaments is accomplished at 
the termination of the curved incision on the inner side of 

16* 



186 EXCISION OF THE ANKLE-JOINT. 

the ankle, and in doing this the proximity of the posterior 
tibial artery is to be borne in mind. The application of a 
very little force will now dislocate the foot, and expose the 
surfaces of the bones comprising the joint, which may then 
be readily excised with the saw, or the whole astragalus 
exsected. 1 

The tibial arteries will sometimes be divided, either 
unavoidably or accidentally, or one of the plantar arteries 
cut across, near its commencement, in removing the as- 
tragalus, la only one case, however, have I known this 
to lead to an alarming hemorrhage. 2 

As has been already intimated, the use of the gouge 
seems generally to be disapproved of. " So far as my 
experience goes," says Mr. Erichsen, " gouging opera- 
tions, even if performed at an early period, are rarely of 
much benefit. I believe that excision ought, as a rule, 
to be practised in preference to gouging, contrary to what 
is the case in the calcaneum." 3 

The application of adhesive straps, in such a way as to 
keep the osseous surfaces approximated, and yet permit a 
free exit to all discharge, and the resting of the foot on 
a pillow, constitute the chief features of the subsequent 
local treatment. 

A deformity resulting from the contraction of the tendon 
of the tibialis anticus sometimes requires attention when 
the parts have healed. Its division with a tenotomy knife, 
in a case capable of improvement, is all which is likely 
to be necessary. 4 

The length of time required for recovery from this op- 
eration is greater than that from any other excision. The 
average period during which 18 of the successful cases 
in the preceding table remained under treatment, those 
being all in which the time is mentioned, was 287£ days, 

1 Commentaries on the Surgery of the War in Portugal, &c., (5th ed., Lond.,) 
p. 91. 

2 Edinb. Med. and Surg. Journ., Jan. 1821. 8 Lancet, June 18, 1859. 
* Med. Times and Gaz., Mar. 31, 1860. 



CONCLUSIONS. 187 

or more than nine months. According to Mr. Sansom, 
the average period required for the healing up of ampu- 
tations of the leg for " diseased bone," is 42 days. 1 



DISSECTIONS. 



Dissection of limbs amputated after excision, or where 
death has taken place after a long interval, the parts being 
healed, does not furnish anything of interest beyond the 
facts of the ligamentous union which is established, and 
an increased mobility in the bones of the tarsus. 



CONCLUSIONS. 



It seems proper to conclude: — 

First, That the earliest excision of the ankle-joint, of 
which there is any record, was by Mr. Cooper, of Bungay, 
England, at some period prior to 1758. 

Second, That in compound dislocation of the ankle- 
joint, not accompanied by too extensive or grave injury 
of neighboring parts, excision is an operation which often 
successfully replaces amputation. 

Third, That, whilst there may be a propriety in excis- 
ing the astragalus in compound dislocations of that bone, 
which cannot be reduced, in other and reducible disloca- 
tions, such a step is improper until its preservation has 
been attempted. 

Fourth, That excision of the ankle-joint is followed by 
a large proportion of failures ; 43.75 per cent of all oper- 
ations being unsatisfactory. Under such circumstances, 
, and in view of the facts that disease of the tarsal bones 
is insidious, apt to reappear, and its entire removal a mat- 
ter of uncertainty, this excision ought to be of infrequent 
performance. i 

1 Mortality after Operations of Amputations of the Extremities, p. 19. 



188 EXCISION OF SMALL JOINTS OF THE FOOT. 



SMALL JOINTS OF THE FOOT 



Excisions practised among the tarsal bones, although 
they implicate articulating surfaces, belong rather to the 
excision of bones than the excision of joints. They are 
usually irregular operations, performed according to the 
necessities of individual cases, and not after fixed and 
systemized rules. Fortunately, disease in this locality, 
especially in young persons, under appropriate constitu- 
tional treatment and rest, manifests a strong disposition 
to recovery without operation. 

The removal of one or more tarsal bones has been oc- 
casionally attempted from a very early period ; and of 
late years, perhaps from the example of Moreau in 1788, 1 
it has become an operation of frequent performance, and 
usually with a considerable degree of success ; often, how- 
ever, only after repetition, a long lapse of time, and no 
little patience on the part of the surgeon. 

On the 8th of December, 1855, Dr. Henry J. Bigelow, 
of Boston, removed the whole tarsus, excepting the os 
calcis and astragalus, together with the tarsal heads of the 
second and third metatarsal bones, by two incisions cor- 
responding to those of Chopart's and Lisfranc's partial 
amputations. The patient, unfortunately, died April 21, 
1856, from exhaustion, not altogether dependent on the 
local disease. 2 

This operation was imitated by Mr. Skey, of London, 
November 27, 1858, and in December the patient was 
doing well. 3 The ultimate result I am unable to give. 

1 Jeffray's Park and Moreau, p. 158. 

2 Records of Bost. Soc. for Med. Imp., Vol. II. p. 342. 
s Lancet, Dec. 4, 1858. 



EXCISION OF SMALL JOINTS OF THE FOOT. 189 

A case cited by Mr. Statham presents some analogies to 
the preceding one. At a first operation the cuboid and 
external cuneiform bones were removed ; at a second, the 
scaphoid and the remaining cuneiform ; and at a third, the 
astragalus was scraped, and the tarsal ends of the second 
and third metatarsal bones were removed. Four years 
afterwards the patient had a foot in which " the natural 
appearance was little altered." 1 

For the removal of the os calcis a regular operation is 
performed. The operations of Mr. Hancock and Mr. 
Greenhow, in June and August, 1848, 2 are claimed to be 
the first instances of this. But it was practised by Mon- 
teggia, of Milan, 3 twenty-five years before, and also by 
Heine in 1834. 4 It has now been performed many times 
for carious disease, and with tolerable success. Of the 
12 cases reported by Mr. Greenhow, 10 were successful, 
and in 2 amputation was subsequently required. The os 
calcis has also been excised for injury ; four operations in 
the Crimea, in the year 1855-56, having all been fol- 
lowed by a favorable result. 5 

There can hardly be a doubt, however, that gouging is 
preferable to excision, and better applicable to this bone 
than to any other of the tarsus ; its use in supporting the 
foot and for the implantation of the tendo Achillis may 
thus be retained, as a portion of the bone and the attach- 
ment of the tendon are preserved by the former opera- 
tion, but can never be by the latter. It appears, also, 
that after complete removal by gouging, — the periosteum 
being left, — the bone has been so nearly reproduced as 
to have been hardly missed ; the tendon obtaining a new 
insertion, and very satisfactory articulations with the other 
bones being re-established. 6 

i Med.-Chir. Trans., Vol. XXXVII. p. 5. 

2 Brit, and For. Med.-Chir. Rev., July, 1853, p. 178. 

8 Vaquez, Quelques Mots sur PExtirpation du Calcaneum. Paris. 

4 Blackman's Velpeau, Vol. II. p. 425. 

5 Med. Times and Gaz., Sept. 13 and 20, 1856. 

6 Arch. Gen. de Med., 5 me sene, Tom. III. p. 677. 



190 EXCISION OF SMALL JOINTS OF THE FOOT. 

Compound dislocations of the great toe at the metatarso- 
phalangeal articulation are so rare that M. Malgaigne 
cites but ten instances. Reduction was effected in six of 
them, for the most part with considerable difficulty ; in 
two the entire metatarsal bone was removed (for what 
reason does not appear), and in two the head of the dis- 
located bone was excised. Of these latter, one recovered 
and the other died. The results which followed the six 
reductions were one death and three recoveries, with the 
exfoliation of the articulating surfaces and anchylosis ; the 
fifth patient left the hospital at the end of two and a half 
months in a condition of which no record is made, and 
the sixth recovered at the end of seventy days with a mov- 
able articulation. 1 In view of these results, and of what 
we know of its adaptation to compound dislocations in 
general, and especially when we consider the difficulty 
which characterizes the reduction of this particular lux- 
ation, excision would seem to be the most judicious method 
of its treatment. The partial removal of the articulation, 
proposed by M. Letenneur, 2 ought to be rejected, in com- 
mon with all excisions of that sort. 

When diseased, the joints of the toes are, as a rule, more 
often treated by amputation than excision ; the anchylosis 
and abbreviation, the scars and prominences, which are left 
by the latter, interfering with comfort when the boot is 
worn ; for although the foot requires a broad surface to 
sustain weight, and a certain length for easy walking, it 
can better bear the loss of a toe, than pressure on an irreg- 
ular and tender cicatrix. 

The metatarso-phalangeal articulation of the great toe 
has, however, been excised quite a number of times for 
caries. This is claimed to have been first performed, and 
with success, by Dr. Joseph Pancoast of Philadelphia, in 
1836. Kramer and Roux, however, are said by 0. Hey- 
felder (p. 203) to have operated as early as 1826 and 

1 Tr. des Fract. et Lux., Tom. II. p. 1093. 

2 L'Union Med., 2 Juillet, 1861, p. 15. 



EXCISION OF SMALL JOINTS OF THE FOOT. 191 

1829. 1 Mr. Hilton, of London, reports a case where the 
patient, with a stout-soled boot, was able after the opera- 
tion to walk over the roughest ground almost as easily as 
ever he could. 2 Mr. Butcher excised this joint success- 
fully, and compensated for the shortness of the inner side 
of the foot by a thin plate of steel, half an inch wide, 
introduced into the sole of the shoe. 3 A partial excision 
performed by Mr. Cock, in which only the head of the 
metatarsal bone was removed, at the end of a year required 
amputation. 4 In a case of Mr. Lane's, three months after 
the operation, the bones had not united, and the necessity 
of amputation was feared. 5 

During the after-treatment, the extensor tendon some- 
times shows a tendency to tilt up the end of the great toe. 
To obviate this, Dr. Pancoast suggests its subcutaneous 
division. 

The head of the second metatarsal bone, without the 
corresponding surface of the first phalanx, was excised by 
Lisfranc, with a successful result at the end of four months ; 
and that of the third, by Yelpeau, with recovery in twenty 
days. 6 M. Chassaignac, upon one occasion, removed three 
fourths of the anterior extremities of the third, fourth, and 
fifth metatarsal bones, exarticulating them at their pha- 
langeal connections. In two months the cicatrization was 
complete. 7 The metatarsophalangeal articulation of the 
little toe has been excised by Mr. O'Doherty, of Dublin, 
and the patient, a girl of sixteen, walked afterwards as 
well as ever. 8 

In three excisions performed by Fricke, of Hamburg, — 
one upon the joint between the first and second phalanges 

1 A Treatise on Operative Surgery, (Philad. 1844,) p. 132. 

2 Med. Times and Gaz., Aug. 6, 1853. 

3 Dublin Quarterly, Feb. 1859. 

* Med. Times and Gaz., Dec. 23, 1854, and April 5, 1856. 

6 Ibid., Feb. 18 and May 27, 1854. 

6 Gazette Medicale, Jan. 1837, p. 54. 

' Bulletin de la Soc. de Chir., 1853, Tom. III. p. 617. 

8 Dublin Quarterly, August, 1859. 



192 EXCISION OF SMALL JOINTS OF THE FOOT. 

of the great toe, for caries, another for an exostosis at- 
tached to the head of the first phalanx of the great toe, and 
the third for a caries of the metatarsal joint of the great 
toe, — the first patient was able to use the extremity at the 
end of five" weeks ; the cure of the second was retarded by 
necrosis of a portion of the bone until the tenth week, and 
four weeks sufficed for the restoration of the third. 1 Re- 
covery followed in all the cases (22) of phalangeal excision 
cited by 0. Heyfelder (p. 205). 

i Dublin Quarterly, May, 1837. 



BIBLIOGRAPHY. 



The following list comprises the titles of all the principal works 
and articles on the Excision of Joints. References to others beside 
these will be found in the preceding pages, but, though important, 
they are such as can hardly be said to form part of the literature 
of the subject. 

On Excisions in general. 

Park. An Account of a New Method of healing Diseases of the 

Joints of the Knee and Elbow. London. 1783. 
Park and Moreau. Cases of the Excision of Carious Joints ; 

with Observations by J. Jeffray. Glasgow. 1806. 
Syme. Treatise on the Excision of Diseased Joints. Edinburgh. 

1831. 
Blackburn. Guy's Hospital Reports. April, 1836. 
Article Arthritis. Cyclopaedia of Practical Surgery. London. 

1837-43. 
Alcock. Medico-Chirurgical Transactions. Vol. XXIII. 1840. 
Cooper. A Treatise on Dislocations and Fractures of the Joints. 

Boston. 1844. 
Chelius. System of Surgery. South's Translation. London. 

1847. 
Syme. Edinburgh Monthly Journal of Medical Science. July, 

1853. 
Guthrie. Commentaries on the Surgery of the War in Portugal, 

Spain, &c. Revised to Oct. 1855. 6th Ed. London. 1855. 
Green. Indian Annals of Medical Science. April, 1855. 
Thornton. Medical Times and Gazette. Sept. 13, 20, 1856. 
Hamilton. American Journal of the Medical Sciences. Oct, 

1857. 

17 



194 BIBLIOGRAPHY. 

British and Foreign Medico-Chirurgical Review. Vol. XX. Oct., 

1857. 
Fergusson. A System of Practical Surgery. 4th Ed. London. 

1857. 
Medical and Surgical History of the British Army which served 

in Turkey and the Crimea during the War against Russia, in the 

years 1854, '55, '56. London. 1858. Vol. II. p. 368. "Blue 

Book." 
Macleod. Notes on the Surgery of the War in the Crimea. 

London. 1858. 
Sedillot. London Lancet. Dec. 10, 1859. 
Gross. System of Surgery. Philadelphia. 1859. 
Druitt. System of Modern Surgery. 8th Ed. London. 1859. 
Wagner. On the Process of Repair after Resection and Extir- 
pation of Bones. Publications of the New Sydenham Society. 

London. Vol. V. 1859. 
Velpeau. New Elements of Operative Surgery. (Am. Trans.) 

4th Ed. G. C. Blackman. New York. 1859. 
Bryant. Diseases and Injuries of Joints. London. 1859. 
Hamilton. Treatise on Fractures and Dislocations. Philadel- 
phia. 1860. 
Erichsen. Science and Art of Surgery. 3d Ed. London. 

1860. 
Stromeyer. On the Fractures of Bones occurring in Gun-shot 

Injuries. Esmarch. On Resection in Gun-shot Injuries. Stat- 

ham. Cases of Resection in Civil Practice. London. 1860. 
Barwell. A Treatise on Diseases of the Joints. London. 

1861. 
Dublin Quarterly Journal of Medical Science, Feb., 1861, p. 100. 
Browne. London Lancet. June 8, 1861. 
Vermandois. Journal de Chirurgie, Medecine et Pharmacie. 

Tom. 66. Janv., 1786. 
Moreau. Observations Particulieres Relatives a la Resection des 

Articulations affectees de Carie. Paris. 1803. 
David (fils). Dissertations sur lTnutilite de 1' Amputation des 

Membres dans la plupart des Maladies de la Contiguite des Os. 

Paris. An XI. (1803-4.) 
Denoue. Essai sur lTnutilite de la Resection des Os dans les 

Membres. Paris. 1812. 
Roux. De la Resection ou du Retranchement de Portions d'Os 



BIBLIOGRAPHY. 195 

Malades, soit dans les Articulations, soit hors des Articulations. 
Paris. 1812. 

Champion. Traite de la Resection des Os Caries dans leur Con- 
tinuity, ou hors des Articulations. Paris. 1815. 

Moreau (fils). Essai sur l'Emploi de la Resection des Os dans 
le Traitement de plusieurs Articulations affectees de Carie. 
Paris. 1816. 

Roux. Revue Medicale. 1830. Vol. XXXIII. p. 1. 

Coulon. De la Carie. Wurtzbourg. 1833. 

Petrequin. Gazette Medicale de Paris. Jan., 1837. 

Malgaigne. Traite de Medecine Operatoire. 5 me Ed. Paris. 
1849. (Chapter on Resections). 

Vidal (de Cassis). Traite de Pathologie Externe. 3d Ed. 
Paris. 1851. 

Boyer. Maladies Chirurgicales. 5 me Ed. Paris. 1853. 

Ollier. Des Moyens Chirurgicaux de favoriser la Reproduction 
des Os apres les Resections. Paris. 1858. 

Ollier. Journal de Physiologie, Janv. et Fevr., 1859, and Tom. 
IV. No. 13. 

LTJnion Medicale. 31 Mai et 7 Juin, 1859. 

Ansiaux. De la Resection des Articulations du Membre Infe- 
rieur. Liege. 1861. 

Chassaignac. Archives Generates de Medecine. 4 me Sefie. 
Tom. XV. 

Heine. Ibid. Tom. I. 1837. 

Wagner. Ibid. 5 me Serie. Tom. I.. III., et V. 

Sedillot. Ibid. Dec, 1859. 

Articles Resection and Humerus. Dictionnaire des Sciences Medi- 
cales. 

Articles Resection, Epaule, Coude, Roignet, Hanche, Genou. Dic- 
tionnaire de Medecine en 30 Vols. 

Meyer. Abhandlung ueber Resection und Decapitation. Er- 
langen. 1829. 

Hummel. Ueber die Resection in Oberarmgelenke. Wiirzburg. 
1832. 

Ahlstuppe. De Resectionibus. Helsingfors. 1840. 

Schirlinger. Beitrage zur Casuistik der Resectionen. Wiirz- 
burg. 1841. 

Textor. Ueber der Wiedererzeugung der Knochen nach Resec- 
tion bei Menschen. Wiirzburg. 1843. 



196 BIBLIOGRAPHY. 

Ried. Die Resectionen der Knochen. Niirnberg. 1847. 
Steinlin. Ueber den Heilungsprocess nach Resection der Kno- 
chen. Zurich. 1849. 
J. F. Heyfelder. Ueber Resectionen und Amputationen. Bres- 

lau und Bonn. 1854. 
Heim. Die Resectionen. Wurzburg. 1855. 
Paul. Die Conservative Chirurgie des Glieder. Breslau. 1859. 
Schillbach. Beitrage zur den Resectionen der Knochen. Jena. 

1859. 
Senftleben. Archiv fur Pathologie, Anatomie, und Physiologie, 

und fur Klinische Medicine. Berlin. 1859. Band XXI. Heft 

3, p. 289. 
O. Heyfelder. Operationslehre und Statistik der Resectionen. 

Wien. 1861. 
Bourbier. Dissertatio de Necessitate et Utilitate earn in Fracturis 

et Luxationibus, Complicatis Ossis portionem Serra descendendi 

quae alterius Repositioni Obnititur. Strasbourg. 1776. 
Koler. Experimenta circa Regenerationem Ossium. Gottingen. 

1786. 
Wachter. Dissertatio Chirurgica de Articulis Extirpandis. 

Groningen. 1810. 
Jaeger. Operatio Resectionis Conspectu Chronologico Adura- 

brata. Erlangen. 1832. 
Wetzlar. De Articulis Resectione. Bonn. 1832. 
Schlitte. De Dignitate Amputationum et Resectionum quae 

Articulis Tumore Albo affectis institutae sunt. Halle. 1836. 
Stebut. De Resectione Amputationi comparata. Dorpat. 1848. 
Petruschky. Dissertatio de Resectione Articulorum Extremita- 

tis Superioris. Berlin. 1851. 
Kyriakos. De Articuli Humeri et Cubiti Resectione. Berlin. 

1854. 
Scymanowsky. Additamenta ad Ossium Resectionem. Dorpat. 

1856. 

On Excision of the Shoulder-Joint. 

White. Cases in Surgery, with Remarks. London. 1770. 
Mann. Sketches of the Campaigns of 1812, 1813, 1814. Ded- 

ham. 1816. 
Gcthrie. A Treatise on Gun-shot Wounds. London. 1820. 
Hennen. Principles of Military Surgery. 3d Ed. London. 

1829. 



BIBLIOGRAPHY. 197 

Syme. Contributions to the Pathology and Practice of Surgery. 

Edinburgh. 1848. 
Baudens. American Journal of Medical Sciences. July, 1855. 
Coote. Lancet. April 20, 1861. 
Sabatier. Memoires de l'lnstitut. Sciences Mathematiques et 

Physiques. Fructidor. An XI. Tom. V. p. 366. 
L arret. Memoires de Chirurgie Militaire et Campagnes. Paris. 

1812. 
Legrand. Sur la Resection de la Tete de l'Humerus. Paris. 

1814. 
Bouchut. Memoires de l'Acad^mie de Chirurgie. Paris. Tom. 

II. p. 109. 
Peret. Sur la Resection des Extremites Articulaires. Paris. 

1850. 
Chaussier. Magasin Encyclopedique. Vol. XXX. p. 531. 

On Excision of the Elbow-Joint. 

Roux. British and Foreign Medico- Chirurgical Review. July, 

1841. 
Syme. Contributions to the Pathology and Practice of Surgery. 

Edinburgh. 1848. 
Blasius. London Lancet. May 31, 1851. 
Fergusson. Ibid. April 1, 1854. 
Syme. Ibid. March 3, 1855. 

Hutchinson. Medical Times and Gazette. July 12, 1856. 
Bickersteth. Liverpool Medico-Chirurgical Journal. July, 

1857. 
Syme. Observations in Clinical Surgery. Edinburgh. 1861. 
Thore. De la Resection du Coude et d'un Nouveau Procede 

pour la Pratiquer. Paris. 1843. 
L'Union Medicale. 19 Juin, 1860. 

Blasius. Beitrage zur Praktischen Chirurgie. Berlin. 1848. 
Tobold. De Articuli Cubiti Resectione. Berlin. 1855. 



On Excision of the Hip- Joint. 

Fergusson. Medico-Chirurgical Transactions. Vol. XXVII. 

1845. 
Boning- American Journal of the Medical Sciences. April, 1845. 
17* 



198 BIBLIOGRAPHY. 

Walton. London Medical Times. April 7, 1849. 

Knox. Ibid. June, 1851. 

Smith. Medical Times and Gazette. Dec. 4, 1852. 

Sayre. New York Journal of Medicine. Jan., 1855. 

Kinloch. Charleston Medical Journal and Review. May, 1857. 

Coote. British Medical Journal. Jan. 2, 1858. 

Erichsen. Ibid. May, 1860. 

Sayre. Transactions of the American Medical Association. Vol. 

XIII. 1861. 
Winne. American Journal of the Medical Sciences. July, 1861. 
Santesson. Dublin Quarterly Journal of Medical Science. Vol. 

XI. p. 432. 
Smith. London Lancet. April 1 and 15, 1848. 
Fergusson. Ibid. April 7, 1849. 
Smith. Ibid. Jan. 2, 1849. 
Walton. Ibid. Jan. 4, 1851. 
Solly. Ibid. Aug. 14, 1852. 
Fergusson. Ibid. April 22, 1854. 
Erichsen. Ibid. Oct. 4, 1856. 
Erichsen. Ibid. Mar. 28, 1857. 
Hancock. Ibid. April 18 and 25, 1857. 
Price. Ibid. April 28, 1860. 
Bonino. Annales de Chirurgie Francaise et Etrangere. Avril et 

Mai. 1844. 
Roux. Gazette des Hopitaux. Mar. 9, 1847. 
Lefort. L'Union Medicale. Sept. 6, 1860. 
Fock. Archives Generates de Medecine. Nov. et Dec, 1860. 
Lefort. Ibid. Jan v., 1861. 
Lepold. Ueber die Resection des Hiiftgelenkes. Wiirzburg. 

1834. 
Walther, Jaeger und Radius. Handworterbuch der Gesammte 

Chirurgie. Leipzig. 1836. 
Oppenheimer. Ueber die Resection des Hiiftgelenkes. Wiirz- 
burg. 1840. 
Gunther. Lehre von den Blutigen Operationen. Leipzig und 

Heidelberg. 1857. 
Textor, d. S. Zweite Fall von Aussagung des Schenkelkopfes 

mit Volkommenen Erfolg. Wiirzburg. 1858. 
Fock. Archiv fur Klinische Chirurgie. Berlin. 1860. 
Santesson. Om Hoftleden och Ledbrosken uti Anatomiskt Pa- 



BIBLIOGRAPHY. 199 

thologiskt och Chirurgiskt hiinseende, jemte en kritiskt Ofversigt 
ofver nagra bland Inflammations, larans vigtigaste Punktur. 
Stockholm. 1849. 
Dircks. De Resectione Capitis Femoris. Wiirzburg. 1846. 

On Excision of the Knee- Joint. 

Crampton. Dublin Hospital Reports. Vol. IV. 1827. 
Buck. American Journal of the Medical Sciences. Oct., 1845. 
Solly. London Lancet. Aug. 14, 1852. 
Mackenzie. Edinburgh Monthly Journal of Medical Science. 

June, 1853. 
Jones. Medical Times and Gazette. July 2, 1853. 
Jones. Medico-Chirurgical Transactions. Vol. XXXVII. 1854. 
Syme. London Lancet. April 21, 1855. 
Coulson. Ibid. Sept. 5, 1855. 
Butcher. Dublin Quarterly Journal of Medical Science. May 

and Nov. 1855, Feb. 1857, Nov. 1860. 
Humphry. Medico-Chirurgical Transactions. Vol. XLI. 1858. 
Medical Times and Gazette. May 29, 1858. 
Price. Contributions to the Surgery of Diseased Joints, with 

especial Reference to the Operation of Excision. London. 1859. 
Pemberton. On Excision of the Knee-Joint. London. 1859. 
Watson. Glasgow Medical Journal. Oct., 1859. 
Solly. London Lancet. April 2, 1859. 

Kinloch. American Journal of the Medical Sciences. July, 1859. 
London Lancet. Aug. 4, 1860, March 23, 1861, May 18, 1861. 
Krackowizer. American Medical Times. Sept. 15, 1860. 
Medical Times and Gazette. May 18, 1861. 
Bulletins de la Societe de Chirurgie de Paris. Sept. et Oct., 

1849. 
Follin. Archives Generates de Medecine. July, 1857. 
Gazette des Hopitaux. 20, 23 Nov., 1858. 
L'Union Medicale. 4, 7, 21 Juin, 1859. 



On Excision of the Ankle- Joint, Astragalus, etc. 

Gernet. Dublin Quarterly Journal of Medical Science. May, 

1837. 
Wakley. London Lancet. April 12, 1851. 






200 



BIBLIOGRAPHY. 



Hancock. London Lancet. Oct. 1, 1859. 

Medical Times and Gazette. Dec. 15, 1860. 

Turner. Transactions of the Provincial Medical and Surgical 
Association. Vol. XL p. 367. 

Broca. Memoires de la Societe de Chirurgie de Paris. Tom. 
II. p. 570. Paris. 1852. 

Broca. L'Union Medicale. 8 Mai, 1860. 

Thore. Archives Generates de Medecine. 4 me SeVie, Tom. 
XXVI. 

Vacquez. Quelques Mots sur l'Extirpation du Calcaneum. 
Paris. 

Rognetta et Fournier Deschamps. Memoire sur l'Extirpa- 
tion de l'Astragale. Paris. 

Osann. Ueber die Resection des Fussgelenk. Wiirzburg. 1853. 

Robert. Mittheilungen von Resectionen am Fuss. Coblenz. 
1855. 



INDEX 



Acetabulum, excision of the, 120. 
Amputations and excisions contrasted, 
11. 
more fatal as they approach 
the trunk, 12. 
Ankle-joint, after-treatment of excision 
of, 186. 
conclusions with regard to 

excision of, 187. 
condition of limb after ex- 
cision of, 184. 
conditions permitting excis- 
ion of, 172. 
contrast between excision 
and amputation of, for 
injury, 175. 
difficulties belonging to ex- 
cision of, for disease, 178. 
dissections after excision of, 

187. 
excision of, and amputation 

compared, 184. 
excision of, 170. 

for compound dis- 
location, 173. 
disease, 177. 
gun-shot inju- 
ry, 173. 
injury, 172. 
general results of excision 

of, for disease, 178. 
history of excision of, 170. 
influence of age upon ex- 
cision, 183. 
length of time required for 
recovery from excision 
of, 186. 
liability to failure of excis- 
ion of, 185. 
operation of excising, 185. 
statistics of excision of, 
for disease, 182. 
injury, 174. 
table of excisions of, for dis- 
ease, 180. 
Astragalus, excision of, for disease, 178. 
compound dis- 
location, 175. 
history of excision of, 172. 
results of excision of, for in- 
jury, 176. ' 
statistics of excision of, for 
compound dislocation, 176. 



Bibliography of excisions, 193. 
Bone, growth of, in length after amputa- 
tion, 155. 

Conditions to which excisions are adapt- 
ed, 4. 
Conservative surgery, first use of term, 4. 

Deformity, excision for, 7. 
Diseased joints, curability of, without ex- 
cision, 9. 
difficulty in the diagnosis 

of, 9. 
effects of good hygienic 
influences upon, 10. 

Effects of conical balls on the bones, 5. 
Elbow-joint, anchylosis after excision of, 
for injury, 50. 
applicability of excision of, 
to compound dislocations, 
49. 
conclusions with regard to 

excision of, 73. 
conditions permitting excis- 
ion of, 48. 
Crimean experience in ex- 
cision of, 51. 
dissections after excision of, 

70. 
excision of, 45. 
excision and amputation at, 
for gun-shot injury, con- 
trasted, 51. 
excision of, for anchylosis, 53. 
and amputation of 
arm, for disease, 
compared, 65. 
for disease, 55. 
gun-shot inju- 
ries, 49. 
injury, 48. 
injury, in civil 
hospitals, 48. 
extent to which bone may 
be removed in excision 
of, 67. 
general results of excision 

of, for disease, 57. 
history of excision of, 45. 
importance of preserving the 
ulnar nerve in excision of. 



202 



INDEX. 



Elbow-joint, influence of age upon excis- 
ion of, 62, 64. 
indications for excision of, for 

disease, 55. 
length of treatment required 

after excision of, 69. 
Mr. Hutchinson on excisions 

of, for injury, 48. 
operation of excision of, 66. 
partial excision of, for dis- 
ease, 68. 
for traumatic 
cause, 52. 
peculiarities in motions of 

arm after excision of, 63. 
poultices in excision of, for 

injury, 52. 
reunion of divided ulnar 
nerve after excision of, 72. 
Schleswig-Holstein experi- 
ence in excision of, 50. 
secondary excision of, 51. 
statistics of excision of, 62. 
table of excisions of, 58. 
usefulness of arm after ex- 
cision of, 63. 
Evidement des os, 40. 
Excision, comparative success of, on the 
two sides of the body, 18. 
M. S^dillot's substitute for, 40. 
of acetabulum, 120. 
ankle-joint, 170. 
astragalus, 175. 
elbow-joint, 45. 
hip-joint, 90. 
knee-joint, 126. 
shoulder-joint, 21. 
small joints of hand, 87. 
trochanter major, 99. 
wrist-joint, 74. 
Excisions and amputations contrasted, 11. 
Excisions, adaptation of, to the two ex- 
tremities, 13. 
deformity left by, 15. 
early experiments with regard 

to, 3. 
for disease, 8. 

injury, Dr. Hamilton on, 5. 
traumatic causeSj general 
approval of, 5. 
general history of, 1. 
imperfect success of, 15. 
in general, 1. 
the Crimea, 7. 

Italian campaign, 6. 
introduction of, 2. 
most frequently applied to 

"white swellings," 8. 
object in performing, 12. 
opposition of French Academy 

to introduction of, 3. 
partial, 17. 

percentage of failure in, 19. 
popularity of, in Great Britain, 4. 
results ofj 14. 

slowness of convalescence from, 
14. 



Excisions, subsequent use of limb the test 

of success in, 13. 
Extent to which bone may be removed 

in an excision, 14. 

Fatal results after excision, causes of, 17. 
Foot, excision of small joints of, 188. 

Hand, excision of small joints of, 87. 
Head of femur, removal of, when sponta- 
neously separated by disease, 105. 
Head of humerus, gouging in place of ex- 
cision of, for caries, 
40. 
removal of, without de- 
stroying the capsular 
ligament, 40. 
Hip-disease, difficulties in the diagnosis 

of, 99. 
Hip-joint, after-treatment of excision of, 
121. 
amputation subsequent to ex- 
cision of, 122. 
conclusions in i*egard to excis- 
ion of, 124. 
condition of limb after suc- 
cessful excision of, 117. 
conditions permitting excision 

of, 92. 
degree of success following 

excision of, 103. 
difficulty in diagnosis of gun- 
shot wounds of, 94. 
dissections after excision of, 

123. 
excision of, 90. 

after wrenches of, 95. 
and amputation at, 
for gu n-shot injury, 
contrasted, 94. 
for anchylosis, 96. 
compound dislo- 
cations of, 95. 
chronic rheumat- 
ic arthritis, 97. 
deformity, 96. 
disease, 97. 
gun-shot inju- 
ries, 92. 
injury, 92. 
malignant dis- 
ease, 92, 97. 
necrosis, 98. 
features of hip-disease bearing 

upon excision of, 101. 
history of excision of, 90. 
influence of age upon excision 

of, 47. 
influence of disease of the ace- 
tabulum upon excision of, 
100. 
operation of excision of, 120. 
statistics of excision of, for dis- 
ease, 116. 
table of excisions of, 
for disease, 106. 
injury, 93. 



INDEX. 



203 



Hip-joint, table of incompleted cases of 
excision of, for disease, 114. 
time required for recovery 
from excision of, 122. 

Injuries of joints, excision for, 4. 

Knee-joint, after-treatment of excision of, 
165. 
causes of cessation in growth 
of limb, after excision of, 
157. 
causes of mortality after ex- 
cision of, for anchylosis, 135. 
conclusions in regard to ex- 
cision of, 169. 
conditions permitting excis- 
ion of, 128. 
contrast between amputation 
and excision of, for disease, 
152. 
dissections after excision of, 

168. 
division of hamstring tendons 

in excision of, 163. 
Dr. 0. Heyfelder's statistics 

of excision of, 140. 
early operations of excision of, 

141. 
excision of, 126. 

for acute disease, 136. 
anchylosis, 133. 
deformity, 133. 
disease, 136. 
anchylosis and 
amputation con- 
trasted, 135. 
gun-shot wounds, 

129. 
necrosis, 136. 
wounds other than 
gun-shot, 131. 
extension of the limb after 

excision of, 162. 
general results of excision of, 

for injury, 133. 
gravity of gun-shot wounds 

of, 129. 
growth of limb after excision 

of, 153. 
hemorrhage after excision of, 

164. 
history of excision of, 126. 
importance of good hygienic 
influences after excision of, 
165. 
inflammation of the bone af- 
ter excision of, 164. 
influence of age upon excis- 
ion of, 150. 
inhalation of sulphuric ether 
in operation of excision of, 
164. 
length of time required for re- 
covery from excision of,166. 
mechanical treatment of an- 
chylosis of, 136. 



Knee-joint, methods of performing the op- 
eration of excision of, 158. 
Mr. Price's conclusions in re- 
gard to excision of, 139. 
oblique instead of transverse 
section of the bones in ex- 
cision of, 160. 
operation of excision of, for 

anchylosis, 134. 
opinions with regard to excis- 
ion of, 138. 
partial excision of, 161. 
perforation of the popliteal 

space in excision of, 163. 
preservation of the ligamen- 
tum patellae in excision of, 
159. 
rarity of circumscribed tuber- 
cular disease in the bones 
of, 137. 
rarity of true anchylosis of, 

136. 
removal of patella in excision 

of, 151. 
results demanded from opera- 
tion of excision of, 137. 
of Barton's operation for 
anchylosis of, 136. 
of excision of, for an- 
chylosis, 134. 
for gun-shot in- 
jury, 131. 
statistics of excision of, 150. 
table of excisions of, for an- 
chylosis, 135. 
for disease, 142. 
prior to 1850, 
141. 
Metacarpo-phalangeal joints, excision of, 
for disease, 87. 
excision of, for injury, 87. 
Metatarso-phalangeal joint of great toe, 
excision of, 190. 
joints of lesser toes, 
excision of, 191. 
MM. Moreau, early operations of the, 2. 

Os calcis, excision of, 189. 

Park, H., first propositions of, with regard 

to excisions, 1. 
Partial excisions, 17. 
Phalangeal joints of fingers, excision of, 
for compound dislo- 
cation, 88. 
of toes, excision of, 191. 
Preservative Surgery, 10. 

Radius, excision of extremity of, for 

chronic inflammation, 77. 
Reproduction of excised bone, 16, 72. 

Scrive, M., experience of, in the Crimea, 7. 

Shoulder-joint, after-treatment of excis- 
ion of, 41. 
anchylosis after excision 
of, 42. 



204 



INDEX. 



Shoulder-joint, complete excision of, 26, 
33, 39. 
conclusions with regard 

to excision of, 44. 
conditions permitting the 

excision of, 24. 
dissections after excision 

of, 43. 
excision of, 21. 

and amputation 
at, for disease, 
compared, 37. 
for anchylosis, 25. 
compound dis- 
location, 27. 
disease, 31. 
exostosis, 32. 
gun-shot inju- 
ry, 25. 
necrosis, 32. 
separation of 
the epiphysis 
by injury, 27. 
history of excision of, 21. 
indications for excision 

of, for injury, 26. 
influence of age upon ex- 
cision of, 36. 
operation of excising the, 

38. 
partial excision of, 27, 33, 

36. 
preservation of long ten- 
don of biceps muscle in 
excisions of, 40. 
primary excision of, 28. 
length of treatment re- 
quired after excision of, 
42. 
less frequently diseased 

than other joints, 32. 
rapid recovery from ex- 
cision of, for injunr, 28. 
results of excision of, for 
•injury, compared with 
expectant treatment, 
27. 



Shoulder-joint, secondary excision of, 29, 
30. 
statistics of excision of, 
for disease, 33. 
injury, 29. 
success of excision of, for 



table of excisions of, for 
disease, 34. 
Small joints of the foot, excision of, 188. 
hand, excision of, 87. 
Shock following excisions, 12. 

Tarsal bones, excision of, 188. 
Trochanter major, excision of, 99. 

Upper extremity, excision of, 21. 

Wrist-joint, after-treatment of excision of, 

84. 

compensatory enlargement of 

end of radius after excision 

of, 85. 

conclusions with regard to 

excision of, 86. 
conditions permitting excis- 
ion of, 75. 
dissections after excision of, 

85. 
excision of, 74. 

for compound dis- 
location, 76. 
fracture, 76. 
disease, 77. 
gun-shot inju- 
ry, 76. 
necrosis, 77. 
history of excision of, 74. 
operation for the excision of, 

83. 
partial excision of, 78. 
statistics of excision of, for 

disease, 79, 82. 
success following excision of, 

78. 
table of excisions of, 80. 



THE END. 



Cambridge : Printed by Welch, Bigelow, and Company. 



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Library of Congress 
Branch Bindery, 1002 



